TWH Sr Objectives

Rotation-Specific Objectives for Neurosurgical Residents on Neurosurgical Services: Senior Rotation at Toronto Western Hospital

During their residency training, neurosurgery residents will perform at least 36 months (42 months for those beginning after June 30, 2010) on clinical neurosurgical services within the teaching hospitals of the University of Toronto. These hospitals include: The Hospital for Sick Children, The Toronto Western Hospital, Sunnybrook and Women's Health Sciences Centre, and St Michael's Hospital. While there are many similarities between the neurosurgical services at each of these hospitals, there are understandably areas of expertise, which differ at each hospital. These are accounted in the following descriptions of rotation-specific objectives for neurosurgical residents on neurosurgical services:

Toronto Western Hospital
The Neurosurgery service at the Toronto Western Hospital (TWH) is the largest in Canada. This service distinguishes itself by providing tertiary and quarternary neurosurgical care to patients with complex neurosurgical conditions affecting the brain and spine. Unique features of the Neurosurgery service at TWH include a combined neurosurgical and orthopedic spinal program, multidisciplinary programs for patients with AVMs and aneurysms, movement disorders and degenerative brain diseases, brain tumors, and epilepsy. Other areas of expertise an
d focus include intra-operative navigation and imaging, surgery for peripheral nerve neoplasms, awake craniotomy for brain tumors with cortical mapping, endovascular therapy for aneurysms and AVMs, and stereotactic radiosurgery for tumors and vascular malformations using the Gamma Knife unit.

Residents typically rotate as junior (PGY1-2) and then as senior residents (Chief resident PGY5-6) at TWH for periods up to 6 months. Throughout their rotations at TWH, residents learn a wide variety of procedures to care for patients with complex neurosurgical conditions

SPECIFIC OBJECTIVES:

At the completion of their rotations at TWH, neurosurgery residents at the senior levels will function effectively as a:

MEDICAL EXPERT/CLINICAL DECISION MAKER

General Requirements

  • Admit patients, record their medical history and physical examination in clinic and ward environment.
  • Assist in the operating room or operate as the principal surgeon under supervision of the attending surgeon.
  • Consult on patients on medical wards, ICUs, outpatient clinics, and emergency department.
  • Make rounds in the various hospital units as assigned, order appropriate medications, tests and other forms of therapy required for continued care, plan discharge with nurse clinicians and charge nurse and write a daily progress note in the chart where appropriate.
  • Attend clinic with a faculty member at least one half day per week as time permits.
  • Provide guidance and direction to the junior residents on the neurosurgery service regarding patient care issues.

Specific Requirements

At the completion of their neurosurgical rotations at TWH, the senior level resident will have demonstrated the following:

KNOWLEDGE

  • A complete understanding of the main acquired adult neurosurgical disorders requiring neurosurgical attention including infectious diseases, head and spinal cord injury, brain tumours, stroke, vascular malformations, and degenerative diseases of the brain and spinal cord.
  • A detailed knowledge of the anatomy of the central and peripheral nervous systems, including the spine and skull, and a working basic knowledge of the other disciplines including physiology, pathology, endocrinology, and neuropsychology.
  • Familiarity with and understanding of diagnostic imaging studies used to investigate the patient with a neurosurgical disorders including EEG, EMG, CT, MRI, MEG, and ultrasound.
  • A comprehensive understanding of the spectrum of neurosurgical procedures that are available for the treatment of the patient with neurosurgical disease.

CLINICAL SKILLS

  • The ability to obtain a detailed history and perform a complete neurological examination in the patient in order to provide a differential diagnosis and localization of diseases affecting the central nervous system.
  • The demonstration of skills in interpreting appropriate general diagnostic tests (hematology, x-ray, chemistry, etc.) for the satisfactory management of patients.
  • The provision of comprehensive ongoing post-operative neurological assessment and care, including neuro-intensive care, to the neurosurgical patient.
  • A superior ability to interpret neuroradiological examinations of patients with all types neurosurgical disorders.

TECHNICAL SKILLS

At the completion of their neurosurgical rotation, senior neurosurgery residents at TWH will have demonstrated a thorough understanding of neurosurgical anatomy, and the technical ability to satisfactorily and safely perform the following procedures:


  • Ventriculostomy including endoscopic third ventriculostomy
  • Burr holes for drainage of subdural hematomas and empyemas
  • Insertion of ICP monitor
  • Craniotomy for traumatic head injuries including extradural hematoma, subdural hematoma, intracerebral hematoma, depressed skull fractures and basal skull fractures, and lobectomy
  • Craniotomy for tumour including intradural removal of primary and metastatic tumours, and tumours in the posterior fossa
  • Awake craniotomy for tumor removal
  • Posterior fossa craniotomy for acoustic schwannoma, trigeminal neuralgia and hemifacial spasm
  • Craniotomy for clipping of intracranial artery aneurysms
  • Craniotomy for excision of AVMs and cavernous malformations
  • Transphenoidal resection of pituitary tumours
  • Lobectomy for epilepsy
  • Craniotomy for invasive monitoring for epilepsy including depth electrodes
  • Utilization of image guidance (neuronavigation)
  • Posterior fossa decompression for Chiari malformation
  • Carotid endarterectomy
  • Performance of stereotactic brain biopsy
  • Cranioplasty
  • Repair CSF leak
  • VP shunt insertion and shunt revision
  • Application of Halo ring and use of cervical spinal traction
  • Laminectomy, decompression and fusion of cervical spinal fracture with instrumentation as required
  • Laminectomy for cervical, thoracic, and lumbar degenerative disc disease
  • Laminectomy for epidural metastatic disease and other spinal tumours including intamedullary spinal cord tumours
  • Carpal and ulnar tunnel decompressions

Under the supervision of the staff neurosurgeon, the senior resident at TWH will assist at various levels in the completion of the following complex procedures:


  • Supratentorial and infratentorial craniotomy for complex skull base lesions
  • Craniotomy for complex aneurysm repair or AVM excision
  • Treatment of pain (including dorsal column/deep brain stimulation), and epidural infusion of analgesics
  • Radiosurgery for arteriovenous malformations and tumours
  • Stereotaxic surgery for movement disorders such as Parkinson's disease and other functional neurosurgery.

COMMUNICATOR:

General Requirements

At the completion of their rotations in neurosurgery, the senior resident in neurosurgery resident at TWH will:


  • Establish therapeutic relationships with the patients and their families
  • Obtain and synthesize relevant history from patients/families/communities
  • Listen effectively to advice and suggestions from faculty and senior residents
  • Discuss appropriate information with patients/families and the health care team including the junior residents on the neurosurgery service

Specific Requirements

At the end of their senior resident rotation at TWH, residents will be able to :


  • Document appropriate histories, physical examinations, and progress notes.
  • Establish communication with the patient and family that supports a trusting and open relationship.
  • Provide information to the patient and family that supports the patient's participation in decision-making.
  • Respond appropriately to patients, families, and colleagues, who express anger, hostility, or a complaint.
  • Share information with the senior resident and faculty that supports teamwork and effective care planning and provision in an expeditious manner.
  • Be sensitive to the needs of patients and their families as they are affected by age, gender, cultural and ethnic perspectives.
  • Be able to communicate in a clear, concise and collegial manner with referring physicians.
  • Be able to present data to a group of peers or allied health personnel in a clear and understandable way at weekly neurosurgery and neuroscience conferences.
  • Learn the avenues of communication with institutional managers and administrators to be able to clearly express the needs of his/her service.
  • Prepare written documentation regarding patient consultations in a timely and accurate fashion.

COLLABORATOR:

General Requirements

During their rotations at TWH, neurosurgery residents at a senior level of training will learn to:


  • Consult effectively with other physicians and health care professionals.
  • Contribute effectively to other interdisciplinary team activities.

Specific Requirements

During their adult neurosurgery rotations at TWH, senior residents will:


  • Learn to communicate with other physicians and health care professionals to contribute effectively to interdisciplinary team activities to improve patient care in the management of surgical disorders that benefit from such approaches.
  • Be able to collaborate with allied health care personnel in developing public education tools.
  • Be able to work with healthcare governance at all levels.
  • Contribute administrative skills to the physician team, including direction to the junior residents on the service.
  • Be able to delegate responsibilities where and when appropriate.
  • Listen to concerns expressed by others providing care and assist in resolving these concerns if appropriate.

MANAGER:

General Requirements

During their neurosurgical rotations, senior residents at TWH will:


  • Utilize resources effectively to balance patient care, learning needs, and outside activities.
  • Allocate finite health care resources wisely.
  • Work effectively and efficiently at TWH.
  • Utilize information technology (eg. searching medical databases) to optimize patient care, life-long learning and other activities.

Specific Requirements

During their neurosurgical rotations, senior residents at TWH will:


  • Learn time management for clinical activity, learning needs and family and recreational activities.
  • Learn to function efficiently and effectively at TWH so as to optimize the application of existing resources.
  • Learn to interact with the larger community to preserve and secure adequate resources for the provision of excellent care.
  • Utilize current information technology for optimal patient care and for personal life-long learning.
  • Direct the complete care of a group of patients on the service of one or more members of the neurosurgical staff (clinical teaching unit) by delegating responsibilities to other members of the team including junior residents and nurse practitioners.
  • Gain exposure to office neurosurgery as time permits.

HEALTH ADVOCATE:

General Requirements

During their neurosurgical rotations at TWH, senior residents will:


  • Identify the important determinants of health affecting patients.
  • Contribute effectively to improved health of patients and communities.
  • Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

During their neurosurgical rotations at TWH, senior residents will:


  • Identify the important determinants of health that affect their patients.
  • Contribute effectively to injury prevention, health maintenance and health enhancement programs in the community.
  • Be effective advocates of practices that enhance health and well-being.

SCHOLAR:

General Requirements

During their neurosurgery rotations at TWH, senior residents will:


  • Develop, implement and monitor a personal continuing education strategy.
  • Critically appraise sources of medical information.
  • Facilitate learning of patients, house staff/students and other health professionals.

Specific Requirements

During their neurosurgery rotations at TWH, senior residents will:


  • Acquire current techniques to appraise sources of medical information and develop, implement and monitor a personal education strategy so as to become life-long learners.
  • Acquire a sufficient awareness of the scientific method, including the principles of epidemiology, in order to critically analyse the literature for continuing medical education and investigation.
  • Learn to facilitate the learning of patients, medical colleagues, both junior and senior, and other health care professionals.
  • Organize the various academic rounds and seminars.
  • Supervise and teach medical students, junior residents, and off-service rotating residents.
  • Guide the clinical and operative decision-making process of the junior residents.
  • Prepare cases for discussion at monthly morbidity and mortality rounds.
  • Review topics for discussion at didactic teaching rounds.
  • Learn the organization and supervision of the neurosurgical clinical teaching unit, including the supervision of the flow of patients in and out of the unit, their diagnostic and operative management as well as their discharge planning.
  • Undertake one or more clinical research projects leading to a presentation and/or publication as supervised by the faculty.

PROFESSIONAL:

General Requirements

During their adult neurosurgery rotations, senior residents at TWH will:


  • Deliver highest quality care with integrity, honesty and compassion.
  • Exhibit appropriate personal and interpersonal professional behaviours.
  • Practice medicine ethically consistent with obligations of a physician.

Specific Requirements

During their neurosurgery resident rotations, senior residents at TWH will:


  • Have a thorough appreciation of the necessity for methods of quality assurance in the delivery of health care.
  • Learn to deliver the highest quality care with integrity, honesty and compassion, and understand the importance of bio-ethical issues in the delivery of health care.
  • Have the deportment of a professional including the demonstration of a sincere, caring attitude in dealing with patients.
  • Fulfill medical, legal, and professional obligations of the specialist.
  • Meet deadlines, be punctual, monitor patients, and provide follow-up.
  • Understand the principles of ethics and apply these in clinical situations.
  • Demonstrate self-assessment, seek and accept advice when necessary.