The Colon and Rectal Surgery Milestone Project

Transcription

1 The Colon and Rectal Surgery Milestone Project A Joint Initiative of The Accreditation Council for Graduate Medical Education and The American Board of Colon and Rectal Surgery June 2013 Examples included

2 The Colon and Rectal Surgery Milestone Project The milestones are designed only for use in evaluation of resident physicians in the context of their participation in ACGME-accredited residency or fellowship programs. The milestones provide a framework for the assessment of the development of the resident physician in key dimensions of the elements of physician competency in a specialty or subspecialty. They neither represent the entirety of the dimensions of the six domains of physician competency, nor are they designed to be relevant in any other context. i

3 Colon and Rectal Surgery Milestones Chair: Charles B. Whitlow, MD Working Group Glenn Ault, MD Jennifer Beaty, MD Bertram T. Chinn, MD Pamela Derstine, PhD, MPHE Laura Edgar, EdD, CAE Karin M. Hardiman, MD Gerald Isenberg, MD Jan Rakinic, MD Anthony Senagore, MD Advisory Group Elisa H. Birnbaum, MD Timothy Brigham, MDiv, PhD Bruce Orkin, MD John Potts, MD David Schoetz Jr., MD Eric G. Weiss, MD ii

4 Milestone Reporting This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies organized in a developmental framework from less to more advanced. They are descriptors and targets for resident performance as a resident moves from entry into residency through graduation. In the initial years of implementation, the Review Committee will examine milestone performance data for each program s residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing. For each period, review and reporting will involve selecting milestone levels that best describe a resident s current performance and attributes. Milestones are arranged into numbered levels. Tracking from Level 1 to Level 5 is synonymous with moving from novice to expert. These levels do not correspond with post-graduate year of education. Selection of a level implies that the resident substantially demonstrates the milestones in that level, as well as those in lower levels (see the diagram on page v). Level 1: The resident demonstrates milestones expected of an incoming resident. Level 2: The resident is advancing and demonstrates additional milestones, but is not yet performing at a mid-residency level. Level 3: The resident continues to advance and demonstrate additional milestones, consistently including the majority of milestones targeted for residency. Level 4: The resident has advanced so that he or she now substantially demonstrates the milestones targeted for residency. This level is designed as the graduation target. Level 5: The resident has advanced beyond performance targets set for residency and is demonstrating aspirational goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level. iii

5 Additional Notes Level 4 is designed as the graduation target and does not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director. Study of milestone performance data will be required before the ACGME and its partners will be able to determine whether milestones in the first four levels appropriately represent the developmental framework, and whether milestone data are of sufficient quality to be used for high-stakes decisions. Examples are provided with some milestones. Please note that the examples are not the required element or outcome; they are provided as a way to share the intent of the element. Two documents are available one with examples, and one without. Some milestone descriptions include statements about performing independently. These activities must conform to ACGME supervision guidelines, as well as institutional and program policies. For example, a resident who performs a procedure independently must, at a minimum, be supervised through oversight. To aid in scoring the milestones, assessment tools are available on the Association of Program Directors for Colon and Rectal Surgery website ( These assessment tools are not required. Answers to Frequently Asked Questions about the NAS and milestones are available on the ACGME s NAS microsite: iv

6 The diagram below presents an example set of milestones for one sub-competency in the same format as the milestone report worksheet. For each reporting period, a resident s performance on the milestones for each sub-competency will be indicated by selecting the level of milestones that best describes that resident s performance in relation to the milestones. Selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated. Selecting a response box on the line in between levels indicates that milestones in lower levels have been demonstrated as well as some milestones in the higher level(s). v

7 Benign Perianal and Anal Disease Processes Medical Knowledge Lists some components of anatomy, physiology, pathogenesis, and histopathology Lists some processes that require urgent management Lists some general elective treatment recommendations Lists some treatment options for disease progression or recurrence Discusses some components of anatomy, physiology, pathogenesis, and histopathology Discusses some processes that require urgent management Discusses mechanism of action for some initial elective treatment recommendations Discusses some treatment options for disease progression or recurrence Demonstrates knowledge of physiology, anatomy, pathogenesis, and histopathology Demonstrates understanding of processes requiring urgent management Demonstrates understanding of initial elective treatment recommendations and their limitations Demonstrates knowledge of treatment options for disease progression or Integrates anatomy, physiology, pathogenesis, and histopathology Distinguishes and justifies urgent vs. elective approaches for initial treatment; distinguishes and justifies appropriate resuscitation preparatory to urgent management Distinguishes and justifies non-operative vs. operative approaches for initial elective treatment Distinguishes and justifies treatment options for The resident discusses some processes that require urgent management. recurrence disease progression or recurrence, including the associated risks, in the context of previous treatment attempts The resident is able to discuss some anorectal disease processes that require urgent management, but differential diagnosis is incomplete. The resident demonstrates understanding of processes requiring urgent management. The resident is able to explain the pathophysiology of anorectal processes that require urgent management, such as abscess; however, he or she cannot articulate the rationale for bedside abscess drainage vs. resuscitation prior to operative drainage. The resident distinguishes and justifies urgent vs. elective approaches for initial treatment; he or she distinguishes and justifies appropriate resuscitation for preparatory to urgent management. The resident correctly identifies and distinguishes Discusses new theories of physiologic disturbance and disease pathogenesis Discusses investigational options for disease treatment and prevention Discusses investigational options for disease treatment and prevention Discusses investigational options for decreasing risks associated with management of disease progression or recurrence owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 1

8 appropriate elective abscess drainage, such as when some spontaneous drainage has occurred, when bedside drainage can be done in appropriate patients, and when patients with specific comorbid factors, such as immunocompromise or diabetes, that require resuscitation prior to operative intervention. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 2

9 Benign Perianal and Anal Disease Processes Patient Care Lists some common diagnoses Lists some options for problems requiring urgent intervention Lists some options for the elective treatment Lists common complications of operative procedures Discusses epidemiology of common diagnoses Articulates options for urgent intervention and some component steps Articulates options for elective treatment and some component steps Articulates variances in progress after treatment implementation and investigational options The resident articulates options for urgent intervention and some component steps. The resident articulates a few operative options in patients who present with severe perianal pain as well as some component steps of procedures, but knowledge of the operative process is incomplete due to an incomplete knowledge of the likely causative processes of this presentation. Demonstrates knowledge of common diagnoses; demonstrates some knowledge of specialty examination Recognizes situations requiring urgent intervention; with assistance, directs appropriate resuscitation and completes indicated intervention With assistance, selects and directs or performs initial elective treatment, operative or non-operative Recognizes disease progression, treatment failure, and complications, and implements management The resident recognizes situations requiring urgent intervention; with assistance, he or she directs appropriate resuscitation and completes indicated intervention. The resident recognizes the possibility of suppurative disease as the causative process and understands that Assesses specific history details in formulation of differential diagnosis; independently performs exam for diagnosis confirmation Independently identifies need for urgent intervention; proficiently directs appropriate resuscitation and selects and completes indicated intervention Independently selects and directs or performs initial elective treatment, operative or non-operative, including discussion with patient regarding riskbenefit analysis Anticipates, diagnoses, and proficiently manages disease progression, treatment failure, or complications in a timely manner The resident independently identifies the need for urgent intervention, proficiently directs appropriate resuscitation, and selects and completes the indicated intervention. Understands and discusses current controversies in disease incidence and prevalence Demonstrates proficiency as a teaching assistant in the component steps of urgent intervention Understands and discusses current controversies in therapy; demonstrates proficiency as a teaching assistant in the component steps of elective operative management Reviews and assesses practice results and uses the information to effectively modify practice owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 3

10 this would require operative drainage, but his or her The resident independently understanding of other obtains the appropriate potential causative processes historical details, performs the and appropriate laboratory appropriate exam to determine assessment and resuscitation the possibility of suppurative requires assistance; the disease, correctly identifies risk resident s knowledge of factors for systemic appropriate anesthetic in this complication of anorectal situation is incomplete; the suppuration, and directs resident requires assistance to appropriate laboratory studies prepare for and perform the for assessment, then directs operative examination and resuscitation as indicated; the properly indicate operative resident correctly determines intervention. when resuscitation is adequate to proceed to the operating room; having requested appropriate form of anesthetic management, the resident independently prepares for and performs the operative examination and correct avenue of drainage of suppuration, or other indicated operative intervention if suppuration is not the causative process. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 4

11 Colonic Neoplasia Medical Knowledge Lists some components of anatomy, pathogenesis, histopathology, genetics, and staging for colon cancer and polyps and polyposis syndromes Lists common agents in neoadjuvant and adjuvant therapy Lists modalities for post treatment Lists common sites and relative risks of recurrence Lists schedule for patients with polyps Lists polyposis syndromes and knows some differences between them Discusses some components of anatomy, pathogenesis, histopathology, genetics, and staging for colon cancer and polyps and polyposis syndromes Discusses mechanism of action for some neoadjuvant and adjuvant therapies Discusses guidelines for post-treatment Recognizes and discusses risk factors for recurrence Discusses postpolypectomy schedule Discusses polyposis syndrome treatment plan, timing, and type of procedures Demonstrates knowledge of anatomy, pathogenesis, histopathology, genetics, and staging for colon cancer and polyps and polyposis syndromes Demonstrates understanding of treatment protocols and complications Demonstrates understanding of stage-based posttreatment Demonstrates understanding of therapeutic options for recurrence Demonstrates understanding of polyp schedule Demonstrates understanding of polyposis syndrome treatment plan, timing, and specific procedures Integrates anatomy, pathogenesis, histopathology, genetics, and staging for colon cancer and polyps and polyposis syndromes Distinguishes and justifies use of specific neoadjuvant agents and protocols for stage-based therapy and complications Justifies post-treatment strategies based upon timing and patterns of local and distant recurrence Distinguishes and justifies palliative vs. curative management of recurrence Justifies timing and procedure type for various polyposis syndromes The resident knows basic TNM stages, but not details within each stage, (i.e., does not know the difference between T1 and T2, but knows the T stage is referring to tumor depth). The resident articulates basic attributes of colon cancer and polyposis syndromes, including treatment and, but is unsure of the exact plan and current guidelines. The resident can explain the treatment approach based on different stages for colon cancer and polyposis, and knows timing of and rationale. The resident can clearly explain multiple treatment modalities, including different folfox/folfiri, when to use Avastin etc.; he or she knows how to manage a patient with polyposis and rectal cancer. Discusses investigational tumor markers and other staging modalities Discusses investigational chemotherapeutic options Discusses investigational modalities for posttreatment Discusses controversial or emerging modalities for management of recurrent disease Discusses advanced genetic and treatment concepts for polyposis syndromes The resident can explain the genetic basis of colon cancer, as well as appropriate markers and how this affects treatment options. For polyposis patients, he or she can discuss treatment of recurrent polyps in pouch and of duodenum. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 5

12 Colonic Neoplasia (polyps, colon cancer, polyposis) Patient Care Lists some imaging options for tumour/node/metastases (TNM) staging Lists some of the surgical options for management and treatment; knows different procedures for polyps, cancer, and polyposis Lists common complications and management of those complications Lists modalities of posttreatment for polyps, cancer, and polyposis syndromes Lists potential evaluation and treatment of recurrence Discusses strategies for imaging, but has limited understanding of interpretation of results Articulates surgical options and some component steps for partial colectomy, total abdominal colectomy (TAC), total proctocolectomy (TPC), restorative proctectomy, and laparoscopic and open techniques Recognizes variances from the normal post-operative course and begins investigation Discusses modalities for post-treatment Formulates an appropriate imaging strategy and interprets results With assistance, selects and completes the component steps for partial colectomy, TAC, TPC, restorative proctectomy, and laparoscopic and open techniques Implements management of complications Understands posttreatment strategies vary by stage Discusses treatment of recurrence and potential complications Assesses imaging information and justifies a TNM-based treatment strategy Independently selects and completes component steps for partial colectomy, TAC, TPC, restorative proctectomy, and laparoscopic and open techniques Anticipates, diagnoses, and proficiently manages complications in a timely manner Directs post-treatment strategies Implements curative vs. palliative intervention for recurrence Discusses evaluation of recurrence The resident lists modalities of post-treatment. The resident discusses modalities for posttreatment. The resident articulates individual components of post-treatment modalities, but is unable to articulate a coherent evidence-based plan of recurrence. The resident understands that post-treatment strategies vary by stage. The resident discusses the rationale for timing and relative strengths and weaknesses of tests based upon stage-specific risks for recurrence, but the patientspecific plan is incomplete. The resident directs posttreatment strategies. For an N1 or N2 patient, the resident directs the threemonth clinical exam, carcinoembryonic antigen (CEA); at one year he or she directs colonoscopy and computed tomography (CT) of pelvis and chest x-ray; schema is evidence-based; he or she Understands and discusses current controversies regarding image-based treatment strategies Demonstrates proficiency as a teaching assistant partial colectomy, TAC, TPC, restorative proctectomy, and laparoscopic and open techniques Reviews and assesses practice results, and uses the information to effectively modify practice Understands and discusses current controversies regarding Understands and discusses evolving management of recurrent disease owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 6

13 then recognizes the signs and symptoms of a leak; following the patient s discharge, he or she appropriately recommends timing for clinical evaluation and imaging. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 7

14 Crohn s Disease Medical Knowledge Lists some components of anatomical distribution, pathogenesis, histopathology, immunology, genetics, and diagnostic information Lists common agents for medical therapy Lists common surgical options Discusses some components of anatomical distribution, pathogenesis, histopathology, immunology, genetics, and diagnostic information Discusses mechanisms of action for drug therapy Discusses indications for surgical intervention Integrates anatomical distribution, pathogenesis, histopathology, immunology, genetics, and diagnostic information Distinguishes and justifies use of specific immunesuppressive and antiinflammatory therapy Justifies appropriate timing and selection of surgical intervention Examples: The resident discusses that the chronic inflammatory process of Crohn s produces full thickness inflammation throughout the gastrointestinal (GI) tract. He or she defines the classic association of linear ulcers, skip lesions, and granulomas (non- caseating) on the pathology and characteristic endoscopic findings. The resident discusses obstruction, fistula formation, abscess, or failure of medical treatment as indications for surgery. Demonstrates knowledge of anatomical distribution, pathogenesis, histopathology, immunology, genetics, and diagnostic information Demonstrates understanding of appropriate use and monitoring of drug therapy Demonstrates understanding of appropriate timing and selection of surgical intervention The resident articulates the need for both image-guided and endoscopic assessment to monitor therapy and guide prognosis. Examples: The potential role of NOD2 mutation as a risk factor in Crohn s is discussed. The resident defines both topdown (tumor necrosis factor [TNF] agents early) and bottom-up (5- aminosalicylic acid [ASA] then steroids then immunosuppressives) treatment options. Assessment of treatment efficacy using the Crohn Disease Activity Index (CDAI) is clearly articulated. Discusses investigational genetic markers, inflammatory mediators, and imaging modalities Discusses controversial or emerging modalities for surgical therapy owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 8

15 Crohn s Disease Patient Care Displays limited understanding of appropriate symptom scoring, imaging, and endoscopic options for disease evaluation List some of the medical and surgical options for management and treatment Lists common complications of disease, medical, and surgical treatment List modalities for disease monitoring and prophylaxis Discusses strategies for imaging and medical therapy based on symptom scoring or disease activity Articulates medical (corticosteroids, immunosuppression, 5 ASA) and surgical (fistula management, lap and open segmental bowel resection, strictureplasty, TPC/Ileostomy) options Recognizes disease progression and variances from normal post-operative course Formulates an appropriate scoring, imaging, and endoscopic strategy and interprets results With assistance selects and completes component steps for fistula management, lap and open segmental bowel resection, strictureplasty, and TPC/Ileostomy Recognizes and implements management of complications Understands and discusses post-treatment and strategies Assesses symptom scoring, imaging, and endoscopic information to develop treatment strategy Independently selects and completes component steps for fistula management, lap and open segmental bowel resection, strictureplasty, and TPC/Ileostomy Anticipates, diagnoses, and proficiently manages complications in a timely manner Directs post-surgical management for and prophylaxis and begins investigations Recognizes strategies for disease monitoring and prophylaxis The resident is aware that there is a CDAI but is unfamiliar with the specifics; he or she is unaware of imaging modalities other than CT. The resident is able to discuss the use of steroids, 5-ASA, and metronidazole, but is unaware of anti-tnf options. The resident requires assistance to manage a Crohn s Disease-associated enterocutaneous fistula, including imaging, control of sepsis, assessment for disease remote from the fistula, nutritional support, medical treatment, and timing to surgery. The resident is able to independently direct the management of enterocutaneous fistula secondary to Crohn s Disease, including imaging, control of sepsis, assess for disease remote from the fistula, nutritional support, medical treatment, and timing to surgery. Understands and discusses current controversies regarding imaging and emerging medical treatment modalities Demonstrates proficiency as a teaching assistant for fistula management, lap and open segmental bowel resection, strictureplasty, and TPC/Ileostomy Reviews and assesses practice results and uses the information to effectively modify practice owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 9

16 Large Bowel Obstruction Medical Knowledge Lists some components of etiology, anatomic distribution, pathophysiology, and clinical staging (when appropriate) Lists common diagnostic modalities Lists endoscopic or surgical modalities for treatment Limited understanding of need for post-treatment definitive therapy, adjuvant therapy, or dependent upon histo-pathology Discusses some components of etiology, anatomic distribution, pathophysiology, and clinical staging (when appropriate) Discusses appropriate diagnostic imaging and endoscopic modalities Discusses endoscopic or surgical modalities for treatment or palliation Recognizes the need for post-treatment definitive therapy, adjuvant therapy, or dependent upon histo-pathology Demonstrates knowledge of etiology, anatomic distribution, pathophysiology, and clinical staging (when appropriate) Demonstrates knowledge of appropriate diagnostic imaging and endoscopic modalities Demonstrates knowledge for endoscopic or surgical modalities for treatment or palliation Demonstrates knowledge and understanding of some post-treatment Integrates symptoms, exams, lab, imaging, and endoscopic findings to develop an appropriate differential diagnosis Distinguishes and justifies appropriate use of diagnostic imaging and endoscopic modalities Distinguishes and justifies appropriate endoscopic or surgical modalities for treatment or palliation Appropriately justifies post-treatment strategies for definitive therapy, adjuvant therapy, or strategies for definitive dependent therapy, adjuvant therapy, upon histo-pathology or dependent upon histo-pathology The resident lists endoscopic or surgical modalities for treatment. The resident is able list endoscopic decompression and surgical resection for treatment in cases of sigmoid volvulus. The resident discusses endoscopic or surgical modalities for treatment or palliation. The resident is able to discuss the roles of surgery and endoscopy for treatment in cases of sigmoid volvulus. The resident demonstrates knowledge for endoscopic or surgical modalities for treatment or palliation. The resident is able to articulate indications and contra-indications for surgery or endoscopic decompression if sigmoid volvulus is present. The resident distinguishes and justifies appropriate endoscopic or surgical modalities for treatment or palliation. The resident is able to articulate and recognize: surgical indications and contra-indications for sigmoid volvulus; determine appropriate procedures to be performed (e.g., primary anastomosis vs resection Discusses investigational diagnostic modalities Discusses investigational diagnostic modalities Discusses controversial or emerging modalities for treatment or palliation Discusses post-treatment controversies and emerging strategies for definitive therapy, adjuvant therapy, or The resident discusses controversial or emerging modalities for treatment or palliation. The resident is able to appropriately discuss the role of resection vs. repeated palliative endoscopic decompression for chronic/recurrent sigmoid volvulus. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 10

17 and diversion); whether ischemia or peritoneal inflammation is present; or if endoscopic decompression is more appropriate in the absence of these findings. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 11

18 Large Bowel Obstruction Patient Care Displays limited understanding of clinical or image-based presentation Lists some medical, image-guided, or surgical options for management and treatment Lists common complications and their management Limited understanding of need for post-treatment strategies for definitive therapy, adjuvant therapy, or dependent upon histopathology The resident displays a limited understanding of clinical or image-based presentation. The resident is able to identify colonic distension, but is unable to determine the need for urgent vs. emergent intervention and studies to distinguish a complete vs. incomplete obstruction. Discusses strategies for clinical- and image-guided therapy with limited understanding of results and benign/malignant etiologies Articulates some component steps for definitive, staged, or palliative treatment using endoscopic, minimally invasive surgery (MIS), and traditional surgical approaches Recognizes variances in medical, interventional, and surgical recovery, and begins investigation Recognizes need for posttreatment strategies for definitive therapy, adjuvant therapy, or dependent upon histo-pathology The resident discusses strategies for clinical and image-guided therapy with a limited understanding of results and benign/malignant etiologies. The resident is able to determine the need for Formulates an appropriate assessment based on imaging and clinical evaluation and discusses options for therapy With assistance selects and completes component steps for definitive, staged, or palliative treatment using endoscopic, MIS, and traditional surgical approaches Recognizes and implements management for failure of nonoperative therapy or surgical complications Demonstrates knowledge and understanding of some components of posttreatment strategies for definitive therapy, adjuvant therapy, or dependent upon histo-pathology Examples: The resident formulates an appropriate assessment based on imaging and clinical evaluation and discusses options for therapy. The resident is able to Appropriately assesses clinical presentation, staging, and imaging, and justifies appropriate therapy Independently selects and completes component steps for definitive, staged, or palliative treatment using endoscopic, MIS, and traditional surgical approaches Anticipates, diagnoses, and proficiently manages treatment failure or surgical complications in a timely manner Appropriately directs posttreatment strategies for definitive therapy, adjuvant therapy, or dependent upon histo-pathology Examples: The resident appropriately assesses clinical presentation, staging, and imaging and justifies the appropriate therapy. The resident is able to appropriately determine if the obstruction is complete Understands and discusses current controversies in assessment and therapy Demonstrates proficiency as a teaching assistant in the component steps definitive, staged, or palliative treatment using endoscopic, MIS, and traditional surgical approaches Reviews and assesses practice results and uses the information to effectively modify practice Discusses controversies and emerging theories regarding posttreatment strategies for definitive therapy, adjuvant therapy, or The resident understands and discusses current controversies in assessment and therapy. The resident is able to identify Stage IV Colo-Rectal cancer and discuss the roles owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 12

19 urgent vs. emergent intervention, discuss the role for CT scan, and contrast studies and endoscopy to identify the degree of obstruction and features suggesting cancer, diverticulitis, inflammatory bowel disease (IBD), ischemia or, extrinsic process as an etiology. formulate an opinion if the obstruction is due to an acute inflammatory process (e.g., diverticulitis or Crohn s) or a chronic stricture from benign or malignant processes. The resident is able to discuss the need for intervention utilizing resection with or without diversion, colonic stent placement, or medical therapy. or resulting in compromised bowel necessitating surgery based upon clinical exam, labs and imaging. The resident is able to determine if the obstruction is incomplete and chronic, and whether a stent should be placed as a bridge to a single stage resection. of systemic therapy with subsequent re-staging, stenting followed by systemic therapy, or resection/diversion followed by systemic therapy. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 13

20 Rectal Cancer Medical Knowledge Lists some components of anatomy, pathogenesis, histopathology, genetics, and staging Lists common agents in neo-adjuvant and adjuvant therapy Lists modalities for posttreatment Lists common sites and relative risks of recurrence Discusses some components of anatomy, pathogenesis, histopathology, genetics, and staging Discusses mechanism of action for some neoadjuvant and adjuvant therapies Discusses guidelines for post-treatment Recognizes and discusses risk factors for recurrence Demonstrates knowledge of anatomy, pathogenesis, histopathology, genetics, and staging Demonstrates understanding of treatment protocols and complications Demonstrates understanding of stagebased post-treatment Demonstrates understanding of therapeutic options for recurrence Integrates anatomy, pathogenesis, histopathology, genetics, and staging Distinguishes and justifies use of specific neoadjuvant and adjuvant agents and protocols for stage-based therapy and complications Justifies post-treatment strategies based upon timing and patterns of local and distant recurrence Distinguishes and justifies palliative vs. curative management of recurrence Discusses investigational tumor markers and other staging modalities Discusses investigational chemotherapeutic and radiation options Discusses investigational modalities for posttreatment Discusses controversial or emerging modalities for management of recurrent disease owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 14

21 Rectal Cancer Patient Care Lists some imaging options for TNM staging Lists some surgical options for management and treatment Lists common complications and management of those complications Lists modalities of posttreatment Lists potential evaluation and treatment of recurrence The resident lists modalities of post-treatment. Discusses strategies for imaging, but has limited understanding of interpretation of results Articulates surgical options and some component steps for transanal excision (TAE), TME, restorative proctectomy, and anterior perineal resection (APR) Recognizes variances from the normal post-operative course and begins investigation Discusses modalities for post-treatment Discusses evaluation of recurrence Formulates appropriate imaging strategy and interprets result With assistance, selects and completes the component steps for TAE, TME, restorative proctectomy, and APR Implements management of complications Understands that posttreatment strategies vary by stage Discusses treatment of recurrence and potential complications Assesses imaging information and justifies a TNM-based treatment strategy Independently selects and completes component steps for TAE, TME, restorative proctectomy, and APR Anticipates, diagnoses, and proficiently manages complications in a timely manner Directs post-treatment strategies Implements curative vs. palliative intervention for recurrence The resident discusses modalities for posttreatment. The resident articulates individual components of post-treatment modalities, but is unable to articulate a coherent evidence-based plan. The resident understands that post-treatment strategies vary by stage. The resident discusses rationale for timing and relative strengths and weaknesses of tests based upon stage-specific risks for recurrence, but the patientspecific plan is incomplete. Examples: The resident directs posttreatment strategies. For an N1 or N2 patient, the resident directs a threemonth clinical exam, CEA; at one year, the resident directs colonoscopy and CT of pelvis and chest x-ray; schema is evidence-based. The resident discusses the components of a digital rectal Understands and discusses current controversies regarding image-based treatment strategies Demonstrates proficiency as a teaching assistant for TAE, TME, restorative proctectomy, and APR Reviews and assesses practice results, and uses information to effectively modify practice Understands and discusses current controversies regarding Understands and discusses evolving management of recurrent disease owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 15

22 exam that describes the nature of the lesion; recommends an endorectal ultrasound (ERUS), and when presented with a T3N1 M0 lesion recommends neoadjuvant chemo-radiation; understands the treatment protocol requires five weeks for completion, followed by a nine-week rest period; reevaluates the patient and recognizes that a lesion at 4cm distal margin is appropriately managed by colon-anal total mesorectal excision (TME); the resident then recognizes the signs and symptoms of an leak; following the patient s discharge, the resident appropriately recommends timing for clinical evaluation and imaging. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 16

23 Rectal Prolapse Medical Knowledge Lists some components of anatomy and physiology of rectal prolapse Lists some imaging options (defecography, air contrast barium enema) and physiologic studies (anorectal manometry [ARM], electromyographic [EMG], Pudendal Nerve Terminal Motor Latency [PNTML], Colon Transit Studies) useful in evaluating rectal prolapse Lists options for treatment of rectal prolapse Discusses some components of anatomy and physiology of rectal prolapse Discusses strategies for imaging and physiology but has limited ability to interpret results Discusses rationale for transabdominal versus perineal techniques for rectal prolapse The resident discusses surgical management but has a limited ability to discuss non-operative management. Demonstrates knowledge of anatomy and physiology of rectal prolapse Demonstrates understanding of appropriate imaging and physiologic evaluation Demonstrates knowledge of success rates for treatment options, and surgical management of anterior compartment prolapse Integrates anatomy and physiology of rectal prolapse Integrates results of imaging and physiologic testing and correlates appropriately with anatomical and physiological abnormalities Justifies appropriate treatment interventions for rectal and general pelvic organ prolapse The resident has Incomplete knowledge of the pathophysiology of rectal prolapse as opposed to other anorectal conditions. The resident demonstrates knowledge of repair types, but requires direction for selection of repair in individual patients. The resident discusses risks and benefits of abdominal vs perineal repair based on comorbidities and examination of individual patients. Proposes investigational research in anatomic or physiologic disturbances Discusses new investigational modalities for rectal prolapse Discusses current controversies in treatment options owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 17

24 Rectal Prolapse Patient Care Lists some imaging options (defecography std x-rays vs. MRI) and physiologic studies (ARM, EMG, PNTML, Colon Transit Studies) useful in evaluation of rectal prolapse Lists options for treatment of rectal prolapse Lists common complications associated with pelvic prolapse surgeries Discusses strategies for imaging and physiology but has limited ability to interpret results Discusses key steps of abdominal rectopexy and resection/rectopexy (laparoscopic vs. open); discusses key steps of perineal repair of rectal prolapse Discusses rationale for rectopexy vs. resection rectopexy Recognizes disease progression and variances from normal postoperative course and begins investigations Formulates an appropriate investigative work-up after conducting appropriate history and physical With assistance, performs key steps of rectopexy, resection/rectopexy, and perineal repair; discusses newer modalities for rectal prolapse With assistance, performs key steps of surgery for rectal prolapse repair Recognizes and implements management of complications Assesses history and physical, imaging, and physiologic data, and justifies treatment strategy Independently performs transabdominal and perineal repair of rectal prolapse; discusses newer ventral rectopexy Independently performs surgery for rectal prolapse; appropriately involves multidisciplinary team for repairs of associated pelvic organ prolapse Anticipates, diagnoses, and proficiently manages complications in a timely manner The resident distinguishes rectal prolapse from other conditions, such as acute hemorrhoidal disease. The resident is able to reduce the rectal prolapse when appropriate, and perform the definitive repair of the prolapse with guidance. The resident Independently performs a definitive repair of rectal prolapse. Reviews and assesses the frequency of time physiology studies would change surgical decisions in personal practice Demonstrates proficiency as a teaching assistant for repair of rectal prolapse and pelvic organ prolapse Discusses current controversies regarding repairs Reviews outcome data collected and uses this data to change practice owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 18

25 Rectovaginal (RV) Fistula Medical Knowledge Lists some components of classification schemes, pathogenesis, and diagnostic information Lists common surgical options Discusses some components of classification schemes, pathogenesis, and diagnostic information Discusses options for surgical intervention Examples: The resident articulates that classification schemes exist which include size, location, and etiology. He or she may articulate other classifications such as high or low. The resident generally categorizes treatment into conservative, local repairs, or complex repairs. Examples: The resident articulates classification schemes by size, location, and etiology. Based on evaluation, the resident is able, with direction from an attending, to integrate diagnostic information and appropriately classify RV fistula. Based on classification, the resident, with direction from an attending, can discuss some of the pros and cons of surgical options based on class of RV fistula. Demonstrates knowledge of classification schemes, pathogenesis, and diagnostic information Demonstrates understanding of appropriate timing and selection of surgical intervention Examples: The resident has sound knowledge of how to classify RV fistulas, but requires some assistance from an attending to integrate clinical and diagnostic information available to appropriately classify the fistula. The resident can articulate various options for surgical intervention, but requires assistance from an attending to select the appropriate intervention based on the classification and underlying etiology. Integrates classification schemes, pathogenesis, and diagnostic information Justifies appropriate timing and selection of surgical intervention, including benefits of one therapy over another and including recurrence rates Examples: The resident correctly classifies the RV fistula based on history and diagnostic information obtained. He or she integrates this clinical information into an appropriate classification. Based on that classification, the resident correctly chooses an appropriate surgical intervention (conservative; or local repair, which may include sealants, advancement flaps, excision, layered closure, etc. vs. complex repair with tissue interposition). While choosing the surgical intervention, the resident Discusses investigational approaches of pathogenesis and diagnosis Discusses controversial or emerging modalities for surgical therapy and approaches to recurrent RV fistula owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 19

26 can articulate recurrence rates, and when more than one option exists for treatment, demonstrates the ability to discuss the advantages and disadvantages of one treatment over another. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 20

27 Rectovaginal Fistula Patient Care Displays limited understanding of appropriate examination, imaging, and evaluation options for disease evaluation List some surgical options for management and treatment Lists common complications of surgical treatment Discusses strategies for imaging and examination of patients based on presenting symptoms Articulates surgical fistula management options (sealants, advancement flaps layered closure, muscle interpositions) Recognizes variances from normal post-operative course and begins Formulates appropriate assessment based on imaging and examination results With assistance, selects and completes component steps of fistula management Recognizes and implements management of complications Assesses symptoms, imaging, and examination to develop an appropriate treatment strategy Independently selects and completes component steps for fistula management Anticipates, diagnoses, and proficiently manages complications in a timely manner investigations Examples: The resident has a limited ability to establish an evaluation strategy, which may include proctoscopy, colposcopy, and use of methylene blue tampon test, vaginography, barium enema, or magnetic resonance imaging (MRI). This evaluation also includes assessment of local tissues. The resident is able to list some of the repair techniques, which may include fibrin sealants, advancement flaps, excision of fistula and layered closure, perinealproctectomy, and tissue Examples: Based on the presenting symptoms, the resident articulates an evaluation strategy, including assessment of local tissues and selecting an appropriate test to initiate evaluation. Based on the evaluation findings and underlying disease process that may exist, the resident can articulate a potential treatment plan based on the options available. The resident still may struggle with the ability to choose a strategy, but is aware of the various surgical options. The resident conducts a targeted examination and evaluation strategy. This evaluation leads to an appropriate diagnosis and assessment of the presenting problem. Based on the evaluation, a surgical treatment plan is developed and the resident is able to articulate components of how the operation is conducted, but is unable to conduct the operation without guiding assistance. Post-operatively, the resident recognizes complications, and with The resident is able to assess the patient without guidance, taking into account possibly underlying disease conditions that may affect evaluation and treatment strategies. Based on the assessment during the examination and evaluation, the resident selects an appropriate treatment strategy and is able to conduct the repair without significant assistance from the attending physician. The resident anticipates potential complications and is able to recognize early onset of symptoms of those Understands and discusses current controversies regarding imaging treatment modalities Demonstrates proficiency as a teaching assistant for fistula management Reviews and assesses practice results and uses the information to effectively modify practice owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 21

28 interposition. The resident is able to list some of the reasons for failure of repair which may be linked to underlying disease such as IBD or radiation injury. Post-operatively, the resident recognizes symptoms that may indicate a failure of the repair has occurred, or other post-operation complication, and initiates evaluation of the same, based on presenting symptoms. guidance initiates evaluation and treatment of complications. complications; the resident initiates evaluation and treatment of the same in a timely fashion. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 22

29 Anatomy and Physiology Medical Knowledge Lists some important muscular components of the pelvic floor and the innervation Lists major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel Lists major hormonal and chemical neurotransmitters involved in the control of intestinal motility and secretion/absorption Lists common functional bowel disorders The resident is unable to differentiate operatively between the internal and external sphincter and their functions. Discusses important muscular components of the pelvic floor and the innervation Discusses major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel Discusses the major hormonal and chemical neurotransmitters involved in the control of intestinal motility and secretion/absorption Discusses common investigational strategies for common functional bowel disorders but has limited ability to interpret results Completely describes important muscular components of the pelvic floor and the innervation With assistance, can demonstrate knowledge of the surgical approaches to the major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel Defines the appropriate evaluation of major hormonal and chemical neurotransmitters involved in the control of intestinal motility and secretion/absorption (disease specific) With help, can formulate strategies for evaluation of common functional bowel disorders, but requires guidance to interpret Assesses history and physical, imaging, and physiologic data and justifies treatment strategy Independently and proficiently demonstrates knowledge of the anatomy demonstrate the surgical approaches to the major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel Independently interprets the physiologic diagnostic studies Anticipates, diagnoses, and proficiently manages the assessment and evaluation of anorectal physiology The resident is able to differentiate operatively between the internal and external sphincter with guidance and discuss some difference in function. With assistance, the resident demonstrates the surgical approaches to the major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel related to specific procedures. The resident independently demonstrates the surgical approaches to the major arterial supply, venous, and lymphatic drainage for the colorectum and small bowel related to specific procedures. Reviews and assesses the frequency of time physiology studies would change surgical decisions in personal practice Demonstrates proficiency as a teaching assistant for the evaluation of functional bowel disorders and altered intestinal physiology Discusses current controversies the assessment of functional bowel disorders Reviews outcome data collected and uses this data to change practice The resident conceives of and conducts investigative studies such as neosphincter. owners grant third parties the right to use the Colon and Rectal Surgery Milestones on a non-exclusive basis for educational purposes. 23