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Goals and Objectives

 

OBJECTIVES: The vascular residency is designed to prepare the resident to function as a qualified practitioner of vascular surgery at the high level of performance expected of a board-certified specialist. The scope of expertise gained will include proficiency in the diagnosis and treatment of diseases of the arterial, venous, and lymphatic systems (exclusive of the heart and intracranial vessels). Expertise will extend to all standard open surgical and endovascular approaches to vascular diseases. Along with the technical expertise, a thorough study of the basic science, pathophysiology, and non-invasive diagnostic techniques will be taught.  These objectives will be gained through completion of the current two-year vascular residency. The culmination of the training is the attainment of board-certification in Vascular Surgery by the American Board of Surgery through completion of the qualifying and certifying examinations.

CONTENT: At the beginning of the rotation, each vascular resident is given an electronic handout containing the basic science curriculum and clinical curriculum for vascular surgery developed by the Association of Program Directors in Vascular Surgery. The resident is also given handouts describing the vascular service and resident responsibilities (a.k.a. Vascular Surgery Made Ridiculously Easy), as well as an anatomy and surgical exposure chapter, an extracranial vascular disease chapter, a TcPO2 chapter, and multiple recent articles pertaining to the treatment of carotid occlusive disease, aortic aneurysms, peripheral arterial disease, renal failure, and venous disease. These are required reading materials. Multiple textbooks and current journals are also available in the vascular office library.

MEANS OF ACHIEVING OBJECTIVES: The vascular resident has ample operative and outpatient clinic exposure in addition to a weekly lecture series and patient rounds throughout the years to develop the appropriate skills and meet the educational objectives. The focus is on education with a gradual increase in autonomy as deemed appropriate with maturity/experience.

SPECIFIC GOALS AND OBJECTIVES BY ACGME SIX GENERAL COMPETENCIES:

These goals are set for the end of the second year of training and are appropriate for both years of training in a graduated manner.

Medical Knowledge:

Goals and Objectives:

• Following the completion of training, the resident should be capable of managing all aspects of the care of the patient with vascular disease beginning with the initial evaluation, through the diagnostic and therapeutic phases. The resident should acquire sufficient knowledge to achieve board-certification and deliver comprehensive vascular care in the tertiary care environment.

• Possess adequate knowledge of the anatomy, physiology and imaging (angiographic and noninvasive) details of the arterial, venous and lymphatic systems.

• Possess a thorough understanding of the pathology of all arterial, venous and lymphatic disorders.

• Describe the pathogenesis and complications of aneurysms, atherosclerotic occlusive disease and non-atherosclerotic disease processes in the various vascular beds (aortic, carotid, peripheral, visceral).

• Understand all available therapies – medical, endovascular, and surgical – and their relative merits and expected outcomes.

• Assess and optimize risks: especially pertaining to the cardiac, pulmonary, and renal systems in these complex patients with multiple comorbidities.

• Understand the principles of nutritional assessment, immunologic response to illness, hematologic derangements (esp. coagulation disorders), and infection.

• Understand unique aspects of diabetes specific to vascular disease.

• Be able to assess all basic and advanced tests employed – CXR, CT scan, CTA, MRA, arteriography, PFT’s, DSE, echocardiography, nuclear cardiac stress tests, etc.

• Understand all noninvasive vascular laboratory studies and their role in patient care.

Means of Teaching and Assessing:

The resident is expected to have a sound foundation of these issues following their general surgery residency. Further development of this knowledge is expected to occur through the ongoing education during the vascular surgery residency. Weekly educational conferences, including conferences presented by residents and the faculty are required. Ongoing education is provided in the clinic and hospital through direct instruction of the vascular faculty. The resident’s progress is assessed by the faculty on an ongoing basis through direct contact with the resident. Direct feedback is given to the residents on an ongoing basis. Periodic formal resident assessment is performed and documented every three months.

Patient Care and Surgical Skills:

Goals and Objectives:

• Following completion of the vascular residency the resident should demonstrate expertise in consultation for appropriate management of common and uncommon vascular disorders and be capable of integrating the preoperative evaluation, intraoperative treatment and postoperative management of patients with all types of arterial and venous diagnoses.

• Perform thorough evaluations of patients with, and at-risk for vascular disease. Become confident, and effective in vascular physical diagnosis. Understand risk factors for vascular diseases and evidence-based indications for vascular interventions.

• Correctly write and present a focused history and physical examination.

• Become proficient in the preoperative assessment of the vascular patient, decision-making process, appropriate diagnostic evaluation, and caring for the patient in the perioperative procedure.

• The resident will acquire operative experience in major arterial & venous reconstructive surgery, including AAA & TAA repair, bypasses for UE & LE occlusive disease, carotid endarterectomy & aortic arch branch vessel reconstruction, renal/visceral arterial bypass, hemodialysis access procedures and surgery for chronic venous insufficiency. (List is not all-inclusive.)

• The resident is expected to acquire basic techniques in endovascular surgery including, but not limited to, endovascular AAA repair, thoracic aneurysm repair, diagnostic arteriography, peripheral angioplasty and stenting, carotid stenting, renal artery stenting, embolization, IVC filter placement, thrombolysis, and other arterial and venous interventional procedures.

• Understand and apply/direct all aspects of post-operative and long-term care of the vascular patient. – airway management, fluid/electrolyte/ fever/infection, wound care, critical care and management of shock and trauma, acute stroke, coagulation

 

Specific surgical skills:

Amputation

Above-knee

Below-knee

Through-knee

Hip disarticulation

Toe, ray, transmetatarsal

Aneurysm

TAA, TAAA

AAA repair

Juxtarenal and Suprarenal AAA

Endovascular

RX of pelvic ischemia

Hemodialysis

All methods of autologous and non-autologous access

Placement of temporary and tunneled vascular access

Limb Ischemia

Acute

Chronic – LEOD, AIOD

Association with diabetes and ESRD

Thromboembolectomy

Trauma

Repair arterial injuries

Control hemorrhage

Ultrasound

Basic techniques of U/S-guided vascular access

Interpretation of Carotid duplex 4 Updated: 09/16/2010

Interpretation of lower extremity arterial exam

Venous disease

Thromboembolic disease management

Varicose vein treatment

DVT Rx and Dx

Visceral

Renal artery bypass

Mesenteric

Specific Endovascular Skills

Endovascular AAA repair

Thoracic aneurysm repair

Diagnostic arteriography

Peripheral angioplasty and stenting

Carotid stenting, embolization

Renal artery stenting

IVC filter placement

Arterial and venous thrombolysis

Other arterial and venous interventional procedures

Means of Teaching and Assessing:

The resident is expected to have a sound foundation of these skills following their general surgery residency. Further development of these skills knowledge is expected to occur through the ongoing education during the vascular surgery residency. Attendance at weekly educational conferences, including conferences presented by residents and the faculty are required. Ongoing education is provided in the clinic and hospital through direct instruction of the vascular faculty.

The mastery of surgical techniques is taught in the operating room. The mastery of endovascular techniques is taught in the operating room and endovascular suite. The vascular resident is allowed to participate actively in all procedures as appropriate to their level of training and ability. This graduated responsibility is determined by the faculty and assessed on an ongoing basis through direct contact with the resident. Direct feedback is given to the residents on an ongoing basis. Periodic formal resident assessment is performed and documented every three months.

Practice-Based Leaning and Improvement:

Goals and Objectives:

• Demonstrate the ability to evaluate the published literature, apply data to patient management, and participate in academic and clinical discussions and conferences.

• Apply this knowledge in the teaching of fellow physicians and trainees.

• Clearly present complications in the Mortality and Morbidity conference.

• Apply lessons learned from review of poor outcomes to improve overall patient care.

• Continued self-assessment and self-education throughout career.

Means of Teaching and Assessing:

• The residents are responsible for presenting periodically at the weekly Wednesday morning conferences and the Wednesday morning M&M conferences with general surgery as well as specific vascular surgery M&M.

• Direct feedback is given to the residents on an ongoing basis.

• Periodic formal resident assessment is performed and documented every three months.

Systems-Based Practice:

Goals and Objectives:

• The resident should be aware of issues of cost-effectiveness when ordering studies, etc.

• The resident should be sensitive to the medico-legal and ethical aspects of the practice.

• The resident should be able to work with the appropriate available technologies (computer-based charting, imaging, etc) in order to ensure high-quality patient care.

• The resident is expected to be in compliance with all aspects of physician documentation as set forth by the participating hospitals.

Means of Teaching and Assessing:

• The resident’s performance in this area is continually observed in the clinic and operating room.

• Direct feedback is given to the residents on an ongoing basis.

• Periodic formal resident assessment is performed and documented every three months.

Professionalism:

Goals and Objectives:

• Being present at all expected times and places.

• Having a professional appearance as appropriate to duties.

• Demonstrate outstanding moral and ethical behavior.

• Be receptive to feedback on performance and demonstrate a desire for professional excellence.

• Demonstrate sensitivity to gender, age, race, and cultural issues of patients and all persons.

• Demonstrate leadership qualities and abilities.

• Achieve and maintain professional competency.

• Perform administrative duties in a timely, efficient manner.

Means of Teaching and Assessing:

• The resident’s performance in this area is continually observed in the clinic and operating room.

• Direct feedback is given to the residents on an ongoing basis.

• Periodic formal resident assessment is performed and documented every three months.

Interpersonal and Communication Skills:

Goals and Objectives:

• Demonstrate good communication skills with patients and their families in all aspects of patient care – out-patient, preoperative, postoperative, etc.

• Demonstrate the ability to interact with all persons on the healthcare team including nursing staff, ancillary/support personnel, fellow residents and colleagues from other specialties.

• Recognize and demonstrate the importance of whole-person care.

• The resident should demonstrate the ability to request appropriate consultation from other medical specialists and interact with such consultants.

• The resident should encourage a pleasant, non-threatening work environment.

Means of Teaching and Assessing:

• The resident’s performance in this area is continually observed in the clinic and operating room.

• Direct feedback is given to the residents on an ongoing basis.

• Periodic formal resident assessment is performed and documented every three months.

STRUCTURE OF LOMA LINDA UNIVERSITY

GENERAL VASCULAR SURGERY RESIDENCY:

The vascular residency at LLU is a two-year residency allowing entry following completion of an ACGME-accredited general surgery residency program and leading to qualification for Vascular Surgery Board eligibility. The general structure of the residency is outlined below.

ROTATIONS:

As of July 2008, with two residents in the program, the structure will be two rotations – one at LLUMC and one at LLVA.

Residency Year

July – September

October – December

January – March

April – June

R – 1

LLVA

LLUMC

LLVA

LLUMC

R – 2

LLUMC

LLVA

LLUMC

LLVA

 

REQUIRED CONFERENCES:

• Morbidity & Mortality with General Surgery: Wednesdays 7:00am - 8:00am

• General Surgery Grand Rounds: (Last Wednesday of the month) 8:00am - 9:00am

• Vascular Didactic Conference (Presented by Resident) / Journal Club: Wednesdays 8:00am - 9:00am

• Vascular Surgery Interdisciplinary Conference (Presented by Faculty) / Case Presentations: Thursdays 7:00am - 8:00am

• CVQI (joint conference with cardiothoracic surgery): Every other 4th Wednesday of each month 7:30am – 8:30am

• Aortic Aneurysm Conference (joint conference with cardiothoracic surgery): Every other 4th Wednesday of each month 7:30am – 8:30am

SUPERVISION: By vascular attending staff

LLUMC:

o Ahmed M. Abou-Zamzam, MD (Division Chief & Program Director, Vascular Surgery)

o J. David Killeen, MD

o Sheela T. Patel, MD

Veteran’s Administration Hospital:

o Christian Bianchi, MD (Chief of Vascular and Endovascular Surgery)

o Jason Chiriano, DO

o Theodore Teruya, MD

Care of the vascular surgery in-patients at the Loma Linda University Medical Center and related entities is provided by a team consisting of attending surgeons, nursing staff, vascular surgery residents, general surgery residents, and therapists.

On the service, the first year (PGY 6) and the second year (GPY 7) residents perform daily working rounds on patients together with the surgery resident (PGY 3) and medical students. The residents are expected to accompany the attending surgeon on his or her rounds and discuss the care plan for patients on a daily basis.

Each resident will do daily rounds under the supervision of the vascular surgeon with whose patients he/she has been assigned to. Once or twice a week, the entire team of residents and attendings will do working rounds together on all patients. Attending surgeons are available 24/7 to answer questions and provide guidance to the residents in their management of patients.

All residents are expected to staff any consults immediately upon evaluation day or night. The attending physician must be notified immediately upon any change in a patient’s status (i.e. transfer to ICU, death, bleeding, need for change in clinical status).

RESIDENT RESPONSIBILITIES:

• Consults: the vascular resident is responsible for overseeing the evaluation of all new consults from 7am to 5pm, and whenever on-call. The resident may delegate initial evaluation to the junior general surgery resident, but the vascular resident is responsible for overseeing the evaluation and ensuring appropriate and timely attending involvement.

• Clinics: the vascular resident is expected to attend all clinics, and any absence must be approved by the attending surgeons.

• Rounds: daily with attendings – as a group whenever possible.

• OR: cases are distributed per vascular resident and all residents are expected in the OR if possible.

• Call: averages every second-to-third night from home for the vascular resident

• Call for Junior general surgery resident averages every second night from home

ORGANIZATION OF VASCULAR DIVISIONS

1). Vascular Surgery is part of the Department of Cardiovascular and Thoracic Surgery at Loma Linda University.

a. The division chief makes administrative decisions in consultation with the Department of Cardiovascular and Thoracic Surgery Chairman and Dean of the LLU School of Medicine. All matters of policy are subject to established medical school, hospital and

departmental policies. The structure of the Division of Vascular Surgery at the VA abides by the VA bylaws.

b. Prospective faculty and/or secretarial/support staff are selected by the division chief and current vascular faculty subject to approval as above at LLUMC. Participating faculty at the VA are determined by the program director and the designated VA coordinator.

c. Vascular Surgery utilizes primarily the Loma Linda University Medical Center and related entities and the Loma Linda Veteran’s Affairs Hospital for training of the vascular resident. The time spent by the vascular residents during the course of their training will be spent equally at the University Hospital and VA. The vascular resident is also able to participate in procedures performed by vascular faculty at other affiliated hospitals on a case-by-case basis. The vascular residency consists of two distinct services – the vascular surgery service at LLUMC and the vascular surgery service at the VA. At LLUMC, the vascular service consists of a vascular resident, as well as a PGY-1 general surgery resident and a PGY-3 general surgery resident. At the VA, the vascular service consists of a vascular resident, as well as a PGY-2 general surgery resident and a PGY-4 general surgery resident.

d. The vascular resident is an integral part of the division of vascular surgery. The resident is responsible for daily inpatient and outpatient care, supervision of general surgery residents on the service, scheduling of cases, and maintenance of morbidity and mortality statistics and performance of the majority of cases on the service. In short, the vascular resident participates in patient care from first referral through surgical care to discharge and through follow-up.

2). Every patient on the vascular surgery service is a referral to one of the attending staff. The vascular service is to function as one “team”. Resident staff performs surgical procedures under the direct supervision of the attending staff at all times. In addition, an attending as well as resident sees all clinic patients. Attending/resident rounds are made on the service on a daily basis including weekends.

The vascular and general surgery residents participate in all phases of patient care and make therapeutic/diagnostic decisions primarily in consultation with attending staff and

dependent on maturity level/competence. Progressive responsibility is accorded the vascular resident as demonstrated by his/her level of expertise, with increasingly independent care of patients allowed during the course of training.

3). Vascular surgery principles are taught by the attending staff as an interrelated discipline in which relevant anatomy and physiology are utilized to explain known pathophysiology. A logical differential diagnosis is outlined and appropriate diagnostic tests are obtained to arrive at a final diagnosis. Resident staff, in consultation with attending staff, then discuss the list of potential medical/surgical/endovascular therapeutic interventions and decide upon a course of treatment.

The vascular resident is taught/supervised on a daily basis in the clinic, on the wards, and during operative cases, utilizing this educational framework. Formal didactic lectures are supplemented by visiting professors and case presentations. Surgical anatomy is taught within these lectures and during vascular exposures in the operating room.

Patient care situations are also used for teaching, with residents providing decisions during all phases of care. Specific additional experience in endovascular surgery is obtained during the course of the clinical years. Experience with the non-invasive vascular laboratory and specifically duplex ultrasound is obtained by performing intraoperative studies and reading studies over the course of the years. The vascular attending will instruct the residents in the interpretation of all tests performed in the ICAVL-accredited vascular laboratory at LLUMC.

4). At LLUMC, the vascular resident call is taken from home and averages every-other night during the week and every-third weekend. At the VA, the vascular resident provides strictly back-up call from home when the PGY-2 general surgery resident is on call. The vascular resident workweek averages 60-80 hours. The vascular resident is assisted on the service by PGY-3 and PGY-1 general surgery residents. These three residents in addition to one or two medical students constitute the vascular team.

Approximately 20 percent of the total vascular surgery caseload is performed by general surgery residents who also participate in all phases of patient care from initial referral to post-discharge follow-up. General surgery residents at the other four integrated hospitals in the general surgery residency also perform vascular cases independent of the vascular resident. The vascular resident manages the vascular surgery service totally independent of the general surgery services, which are headed by PGY-5 general surgery residents. Vascular and senior general surgery residents are never in direct competition for cases.

5). The vascular resident formally evaluates the fellowship twice per year and evaluates the attending staff at the end of each rotation.

6). Support services from the hospital are available 24 hours a day, seven days a week, including dialysis, radiology, laboratory, etc. as well as an on-call room for the vascular and general surgery residents and cafeteria services.

7). Vascular Surgery Moonlighting Policy

While we do not seek to intrude in our resident’s personal lives, moonlighting has an impact on a resident’s ability to dedicate himself/herself to the training program. Therefore, because residency education is a full-time endeavor, we prohibit resident moonlighting of any type. Residents found to be in violation of this policy will be subject to disciplinary action.

Progression of Resident Responsibility/Skills

During the R-1 year, the resident is already expected to be highly functioning and skilled, as they have already completed an entire general surgery residency. The R-1 is expected to be able to manage all aspects of supervision of the inpatient and outpatient care of the vascular patients, including appropriate initial evaluation and developing a plan for treatment. The R-1 will be responsible for directing the junior residents on the service (PGY-1 and PGY-3). The R-1 and R-2 are always under the direct supervision of a staff member. The R-1 is expected to begin to progress in the surgical proficiency of managing at first less complex, first-time procedures in the operating room. Initially the R-1 should gain expertise in standard endovascular aneurysm repair, open repair of infrarenal aortic aneurysms, carotid endarterectomy, femoral-popliteal and tibial bypasses, dialysis access, and varicose vein surgery. During the progression of the residency the R-1 should be able to handle more complex procedures (open and endovascular) including juxtarenal aortic aneurysms. By the second year the resident should show the ability to manage suprarenal aneurysms, thoracoabdominal aneurysms, repeat tibial artery bypasses, carotid stents, renal stents and complex non-atherosclerotic diseases. All this progression will be monitored by the attending physicians and gradual autonomy given to the resident as appropriate by demonstrated ability.

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