UWMC Roosevelt Clinic Rotation Goals 2011 Procedural Dermatology Fellowship Program 1

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1 Procedural Dermatology Fellowship Objectives University of Washington Medical Center-Roosevelt Rotation The primary goal of the University of Washington rotation of the Procedural Dermatology fellowship is to provide comprehensive training for the fellow in the areas of cutaneous oncology, Mohs micrographic and reconstructive surgery, as well as some aspects of cosmetic surgery (non resurfacing lasers, hair transplantation). The knowledge and skill will be gained through a program of progressive and comprehensive learning designed to add to the base of knowledge and skill acquired during prerequisite dermatology residency Rotation Goals and Competency-Based Learning Objectives: A. Patient Care: Fellow must provide compassionate, appropriate and effective care in the diagnosis and treatment of cutaneous skin disease 1. Consistently gathers a relevant dermatologic history especially as related to procedural dermatology. 2. Efficiently performs and documents a complete or relevant focused exam of the skin and other organ systems relevant to the patient s treatment 3. Consistently uses appropriately and accurately the language of dermatologic surgery (e.g. anatomic terms). 4. Consistently and proficiently identifies benign, premalignant and malignant skin lesions both with clinical inspection, use of loupes and using dermatoscopy where appropriate. 5. Develops effective time management skills to accommodate increasing patient volumes and educate others in effective time management techniques. 6. Consistently and accurately selects clinically appropriate and most cost-efficient ancillary studies (such as biopsies, laboratory studies and radiology studies) in the management of patients. 7. Demonstrates routinely a rational and evidence-based approach to the diagnosis and treatment of skin cancer. Routinely balances the variables in skin cancer presentation that can affect treatment choice. Routinely takes into account the balance goals of cure, cosmetic and functional result with choice of therapy. 8. Formulates an increasingly independent plan of care prior to presenting to the attending dermatologist and support staff. 9. Assumes a leadership role in the preoperative assessment of patients and demonstrates competence in: Selection of surgical therapy Selection of alternative therapy if appropriate Counseling patients on risks, benefits, and alternatives Obtaining informed consent Preoperative assessment Identifying and involving consultants or other specialists as appropriate 1

2 10. Shows consistent and thorough knowledge and competence in safe and comfortable use of local anesthetics and effectively supervise more junior learners such as residents including: Selection of appropriate types of local anesthetics Routinely applying methods to decrease the pain of anesthetic administration Knowledge of safe dose and Anesthetic toxicity 11. Consistently demonstrates competence in cryotherapy. 12. Consistently demonstrates competence in electrosurgery, including treatment of rhinophyma 13. Demonstrates competence in nail surgery. Cutaneous Oncology and Mohs Micrographic Surgery 14. Can competently perform skin tumor destruction, specifically: desiccation and curettage, cryotherapy, photodynamic therapy, excisional surgery, and Mohs micrographic surgery. 15. Consistently demonstrates competence in excisional skin surgery of benign and malignant lesions, including: selection of appropriate lesions and closure technique the appropriate surgical anatomy issues for the above procedures on most body sites principles of relaxed skin tension lines, contour lines and cosmetic units and demonstrates their incorporation in surgical planning. options and choices for suture materials and other closure materials and appropriately chooses material. skilled performance of the above procedure with minimal need for supervisory observation. appropriate use of hemostasis, undermining and suturing techniques risks to operator and assistant during surgery and can educate learners about these risks. rem of complications of the above procedure. 16. Demonstrates competence and excellence in performance of Mohs Surgery, including all of the above items listed for excisional surgery as well as specific to Mohs surgery: Indications Technique in cases of varying complexity Risks and Benefits Consistent and accurate preparation and interpretation of frozen sections Reconstructive Surgery 17. With increasing competence, can discuss the surgical options for dealing with acute surgical cutaneous defects with a nuanced discussion of the options and can perform competently: 2

3 Second intention healing Primary Closure, including wedge resection ear and lip Skin Grafts Local Flaps, including two-stage flaps 18. Routinely demonstrates practical wound healing principles to surgical wounds of the skin including appropriate selection of wound dressings. Cosmetic Procedures 19. Consistently is able to discuss with patients indications for laser surgery and: Expected Outcomes Risks and Benefits Management of Complications 20. Demonstrates ability to perform laser surgery with minimal supervision 21. Demonstrates increasing competence in a range of additional cosmetic procedures provided at the UWMC site in dermatologic surgery including: dermabrasion of scars hair transplantation scar revision rhinophyma repair B. Medical Knowledge: Fellow should be comprehensively knowledgeable about biomedical, clinical and epidemiological science as they relate to surgical care of the skin. 1. Demonstrates a comprehensive knowledge base in the basic sciences relevant to dermatologic surgery. Consistently applies the principles of biology, cutaneous oncology, immunology and genomics, including molecular diagnostic techniques and pathology of skin tumors, to the counseling and management of patients with dermatologic disorders that present to the procedural dermatologist. 2. Demonstrates a comprehensive knowledge base in surgical diagnostics and therapeutics used in dermatologic surgery, including a) cutaneous oncologic surgery, b) cutaneous reconstructive surgery and c) cutaneous cosmetic surgery a) Cutaneous oncologic surgery consisting of medical, surgical and dermatopathology components for the management of cutaneous neoplasms. The fellow is expected to develop in-depth knowledge and abilities in early identification, the clinical diagnosis, pathophysiology, and pathology of skin tumors as well as laboratory and pathologic interpretation related to surgical treatment. Further, he/she must become skilled at the early identification of benign premalignant and malignant skin lesions. 3

4 The fellow must understand and appropriately choose and perform a wide variety of procedural treatments including cryotherapy, electrosurgery including curettage and desiccation, excisional surgery and Mohs surgery. Specifically with Mohs surgery the fellow will demonstrate understanding of treatment of aggressive tumors, large tumors, tumors arising in difficult anatomic sites (ears, eyelid, nose, lips), tumors requiring complex histopathologic interpretation, basal cell or squamous cell carcinoma that has spread from skins to contiguous tissues, tumors requiring multiple stages of excision recurrent tumors, tumors for which management requires the involvement of colleagues from other specialties, and tumors in patients with complex medical problems requiring special intraoperative management. The fellow will gain experience working with colleagues in medical dermatology, dermatopathology and oncology as well as in radiation oncology, general surgery, facial plastic surgery (ENT), oculoplastic surgery (ophthalmology) and general plastic surgery. The fellow will acquire experience in operating a frozen section laboratory and will understand how to set up such a laboratory as well as train and superve laboratory personnel. The fellow will demonstrate knowledge of nail surgery. b) Cutaneous reconstructive surgery consisting of the repair of skin defects resulting form surgical removal of tumors or other skin diseases and revisions of scars including rhinophyma correction. These techniques require knowledge of cutaneous wound healing and preservation of normal cutaneous anatomy while utilizing simple closures and advanced closure techniques including wedge excisions as well as flaps (both random and axial) and skin grafts. c) Cutaneous cosmetic surgery focusing on the study and performance of procedures that have been developed by medical specialties to improve the appearance of the skin. This will incorporate medical, surgical and dermatopathologic knowledge of cutaneous disorders, aging skin, and healing physiology. Specifically the fellow will demonstrate knowledge of:injectables (fillers and botulinum toxin) Resurfacing Procedures (laser and chemical peels) Laser Surgery Liposuction Hair Transplantation Scar Revision, including dermabrasion Treatment of rhinophyma 3. Fellows will expand and demonstrate their knowledge of related areas such as surgical anatomy, sterilization of equipment, aseptic technique, anesthesia (including preoperative sedation, local and regional anesthesia and indications for conscious sedation and general anesthesia), closure materials (sutures, stapes), and instrumentation. Appropriate evaluation and management skills must be mastered for cutaneous surgical patients regardless of diagnosis, including preoperative, perioperative, and postoperative evaluation. This will include choosing appropriate ancillary tests (radiology, bloodwork, pathology) for both tumor staging and preoperative evaluation. Fellows will be expected to demonstrate knowledge of wound healing, including basic science, clinical aspects, and the use of specialized wound dressings appropriate to the clinical problem will be acquired. 4. Fellows will demonstrate that they understand the use and role of consultants in associated specialties (oculoplastic surgery, plastic surgery, hand surgery, general surgery, radiation oncology, facial plastic surgery) C. Practice-based learning and improvement: Fellows should be able to investigate and evaluate their surgical practices, appraise and assimilate scientific evidence, and improve patient care practices. 4

5 1. Comes prepared and participates in didactic conferences. 2. Demonstrate active, self-directed learning and share relevant medical knowledge with the team. 3. Efficiently accesses best-evidence for clinical decision making. 4. Can articulate a recognition of errors in patient care, gaps in core knowledge and suboptimal interpersonal communication and takes steps to correct them. 5. Actively seeks improvement in clinical efficiency 6. Applies newly acquired medical knowledge to patient care and regularly places this knowledge within the framework of individual experience, developing an evidence-based approach to treatment of cutaneous neoplasms. 7. Maintains appropriate records documenting practice activities (ACGME surgical logs). 8. Identifies remaining gaps in training early and actively seeks opportunities for exposure in these areas. 9. Nurtures the habit of critical reading of the medical literature to remain current in dermatology, dermatologic surgery and related fields. 10. Synthesizes information from a variety of sources, including print and electronic, and is effectively able to reconcile differing information from different sources. 11. Observes use of infection log (maintained at UW) and its use in practice monitoring and improvement. 12. Demonstrates understanding of difference in technique used by different surgeons and able to choose rationally among those observed/learned approaches. 13. Prepares a scholarly project suitable for publication or presentation at a dermatology meeting or presents at a local, regional or national professional society meeting. D. Interpersonal Communication: Fellows must be able to demonstrate interpersonal and communication skills that result in effective information exchange and a spirit of cooperation with patient/families and other health-care professionals 1. Empathically listens, with attention to cross-cultural issues and able to handle difficult and varying patient interactions. 2. Consistently uses a compassionate, and respectful demeanor in the work setting. 3. Effectively communicates with other physicians and staff in a manner that respects patient privacy. 4. Develops and maintains positive interactions with support 5. Effectively counsels and educates patients, and caregivers 6. Presents patient information completely and lucidly. 7. Functions effectively as an integral part of a team Offers sensitive and constructive feedback. 8. Actively solicits feedback on performance and responds positively to appropriately delivered feedback. 9. Communicates clearly with referring physicians in written language. 10. Documents in the medical record all interactions with patients thoroughly and accurately. 11. Effectively summarizes and publicly presents a critical analysis of unusual patient case, following review of the medical literature. 12. Is actively and effectively involved in teaching of dermatology (and other) residents. 5

6 E. Professionalism: Fellows must be committed to their professional responsibilities adherence to ethical principles and social sensitivity 1. Consistently demonstrates ethical conduct. 2. Creates and maintains healthy and positive relationships with residents, faculty and any students. 3. Consistently displays emotional maturity. 4. Consistently demonstrates dependable behavior in patient care, and other tasks. 5. Consistently dresses in a neat, appropriate and professional manner. 6. Consistently is punctual for clinical work and didactics. 7. Consistently demonstrates respectful behavior toward faculty, staff, co-residents, students, and patients. 8. Demonstrates sensitivity to issues of culture, age, gender, and disability. 9. Demonstrates initiative in patient care. 10. Demonstrates initiative in resolving conflicts. 11. Considers and grapples with ethical issues including, informed consent, cost of medical care, billing and compensation issues, withholding of care, appropriateness of treatment. F. Systems-based practice: health-care system Fellow must demonstrate an understanding of and responsiveness to the 1. Demonstrates a comprehensive knowledge of cost-effective care. 2. Understands how different practice systems function to deliver care, including both academic and private procedural dermatology practices. 3. Effectively utilizes non-dermatologist staff effectively as part of the health care team, including: Ancillary medical staff, Clinic administrative staff, Medical Interpreters, Mohs histotechnologists. 4. Demonstrates when and whom to call for appropriate consultation. 5. Positively interacts with non-department healthcare providers. 6. Continues to learn and demonstrate the rules of documentation and coding of a given level of patient care and for procedures. 7. Demonstrates an ability to educate more junior learners in documentation and coding. 8. Applies the knowledge of health care financing, coding and documentation regulations to appropriately manage financial issues involved in patient care. 6