Orthopedic Surgery Goals and Objectives FOOT AND ANKLE ROTATION Preamble Residents will complete a junior and a senior foot & ankle rotation during their training. The expectations, goals and objectives will vary by level of training and are outlined below. The resident will have two faculty supervisors in order to concentrate their experience and maximize their ability to achieve the competencies outlined below. This will necessitate that the resident organize their clinical duties accordingly so that they can ensure that faculty know when and where they should expect to engage the resident in a learning environment. In addition the resident should expect to follow all the patients that they operate on while the patients are in hospital. This rotation will be a challenge from an organizational point of view for the resident, but with proper attention and preparation by the resident it will prove to provide an exemplary exposure to both routine and complex foot and ankle pathology. CanMEDS Roles Residents who rotate on the foot and ankle service will have the opportunity and be required to further develop their competence in roles beyond the medical expert. The rotation(s) lend themselves to emphasizing certain roles specifically and these will be the focus for learner development and evaluation. Collaborator Junior Level Orthopedic surgeons collaborate with allied health care professionals on a daily basis to provide optimal patient care. Treating patients with foot and ankle pathology lends itself well to expose learners to the collaborator role. We will capitalize on this opportunity to advance the learners collaboration skills. The outline of this learning experience is as follows: - Residents on rotation will select a patient from one of their clinical encounters who has complex needs regarding orthoses / bracing - Informed consent will be obtained from the patient - Residents will attend and participate in that patient s assessment by an orthotist - Residents will participate in the planning and possibly fabrication of the device - Residents will obtain information regarding what programs are available to patients who require assistance in paying for their device(s) Evaluation of this role will be provided by the orthotist in the form of a multi-source feedback evaluation. Communicator Senior Level Unfortunately, many patients with pathology of the foot and ankle do not have salvage options available to them. Communicating effectively with a patient and their family when limb ablation is the recommended treatment is crucial. This is often a devastating event for the patient and their 1
family members. Having a caring and compassionate physician who can communicate effectively leading the health care team will have a positive effect on the outcome. Residents will be observed in the communicator role. Expectations are as follows: - The treatment recommendation is clearly outlined - The physician exhibits the appropriate level of care and compassion - Patient expectations are obtained and addressed as required - Culture specific issues regarding amputation are addressed as required Evaluation of this role is by the staff physician as an observed clinical encounter. Required Reading There are many excellent sources available to the learner. These are available in print and electronic form. M Coughlin & Mann s textbook of Foot & Ankle surgery is a mainstay. AAOS OKU Foot & Ankle is recommended. AAOS Advanced Foot & Ankle reconstruction is recommended for the senior resident rotation. The material is available from other sources as well. The resident is expected to acquire adequate resources and become familiar with the material prior to their rotation. Evaluation Evaluation of a resident s performance is of paramount importance. All evaluations are the responsibility of the resident to ensure timely completion by the appropriate individual. Review of goals and Objectives Junior Level Requirements 1) Mid-term ITER 2) A final ITER is to be completed at the end of the rotation 3) Surgical Competency Assessment of Resident (SCAR): 4 are to be completed during rotation. For example: forefoot procedure: either simple bunion correction or 1 st MTP fusion 4) Point of Care Clinical Encounter (POCCE): 4 5) Collaborator Multisource Assessment Orthotist Senior Level Requirements 1) Mid-term ITER 2) A final IETR is to be completed at the end of the rotation 3) Surgical Competency Assessment of Resident (SCAR): 6 are to be completed during the rotation. For Example hind foot fusion / osteotomy or major forefoot reconstruction 4) Point of Care Clinical Encounter (POCCE): 4 5) Observed Surgical Encounter (OSE) 6) Communicator Observed Clinical Encounter (OCE): Limb ablation consent as described above 2
The resident will achieve the following competencies during the rotation. A. Medical Expert Medical Expert Junior Level - Patient assessment o Be able to take a focussed patient history o Recognize what elements of the history are critical to the Foot & Ankle o Demonstrate ability to properly examine the Foot & Ankle o Describe what constitutes a normal exam o Properly assess deformities of the Hindfoot, Midfoot and Forefoot o Apply specific tests relevant to foot and ankle assessment in the clinical setting o Understand lower limb alignment and its effect on the Foot & Ankle o Have knowledge of common conditions causing pain and/or deformity in the Foot & Ankle o Provide differential diagnosis for common conditions assessed o Counsel patients and obtain appropriate informed consent for procedures listed below including Expected course & outcome Potential complications - Gait o Describe the components of normal gait and how it is evaluated o Describe the pathologic types of gait o Be able to evaluate gait in the clinical setting - Medical imaging o Employ imaging modalities in an appropriate manner o Recognize when imaging has been inappropriate to the condition evaluated o X-Rays Describe what constitutes a normal exam Describe common measures used in the foot and ankle imaging Recognize common pathologies o CT Discuss appropriate use of CT Evaluate common pathologies on CT o MR Describe normal anatomy Review pathology with MSK radiology o Nuclear medicine Describe appropriate / useful employment of nuclear medicine in patient evaluation - Non operative treatment of common foot & ankle pathologies o Describe which conditions can effectively be treated without surgery o Orthotics and bracing Describe what orthotics and braces are available Recognize the common orthoses and braces Describe how to prescribe them appropriately for common conditions o Injections Describe what conditions are amenable to therapeutic injections Describe how to apply diagnostic injections in clinical decision making 3
Describe how to perform common injections/aspirations Ankle MP joint Morton s Neuroma, Plantar Fascia Local blocks - Foot at Risk / Ulceration o Recognize which patients have feet at risk o Recognition and management of host factors critical to feet at risk Diabetes Smoking o Properly evaluate ulcers o Initial assessment & management of Diabetic / Charcot foot o Initial assessment & management of ischemic / gangrenous foot - Post Op Management o Formulate appropriate post operative plan for all patients o Manage in hospital care and discharge appropriately o Utilize transportation and community resources efficiently o Prescribe appropriate rehab for all patients o Diagnose and treat common complications following operative and non operative treatment Surgical Treatment - Describe and perform common surgical approaches in the foot & ankle - Understand, assess and provide a surgical plan for common foot and ankle pathologies amenable to surgical treatment - The resident should be able to perform the following procedures by the completion of their rotation o Basic surgical skills Positioning, prepping and draping for common procedures Handling of soft tissues Wound closure Application of splints / casts o Surgical treatment of soft tissue conditions Excision of ganglia Excision Morton s neuroma Excision / release plantar fascia Decompression tarsal tunnel Tendon: repair, release, lengthening & tenodesis Fasciotomy Simple stabilization - Ankle o Surgical treatment of forefoot deformity primary cases Hallux Rigidus fusion, chielectomy Hallux Valgus Soft tissue release Bunionectomy 4
Simple osteotomy (metatarsal) o Ankle arthroscopy Diagnostic o Trauma not a trauma rotation per se, however the resident will have opportunities to treat fractures during the rotation in accordance with their own & staff call duties Simple ankle fractures Metatarsal fractures Medical Expert Senior Level Expectations for residents at the senior level include those of the Junior level and those below - Patient assessment o Residents at the senior level should have an expanded ability to evaluate patients building on their junior level knowledge and experience. As such, the expectations evolve to include mastery of more complex problems o Evaluation includes obtaining an appropriate patient history, physical examination and assessment of medical imaging in particular: Degenerative and inflammatory arthritis of the Foot & Ankle Deformity of the lower limb including the hindfoot, midfoot and complex deformity of the forefoot Neurologic conditions affecting the foot and ankle Revision Understand the factors that contribute to failure / recurrence of common procedures Recognize what revision / salvage options are available Counsel patients appropriately Surgical Treatment - Management o Planning incisions for complex cases including revision cases o Awareness of equipment needs and availability - Fusion including positioning, prepping, draping & exposure o Ankle o Subtalar o Revision MTP o Midfoot fusion arthritis, deformity, post traumatic - Arthroplasty o Describe contraindications & indications o Counsel patients appropriately o Exposure - Forefoot deformity o Revison Hallux valgus o Complex forefoot osteotomy o Hallux varus o Rheumatoid forefoot o Lesser toe deformity - Hindfoot Mid Foot deformity o Calcanel osteotomy o Mid foot osteotomy - Soft tissue 5
o Tendon release/transfer relating to deformity & neurologic conditions of paralysis or spasticity o Revision stabilization Ankle - Limb Salvage o Indications & contraindications to limb salvage surgery o Techniques for salvage of Charcot arthropathy - Trauma o Complex intra-articular fractures & dislocations Pilon, Calcaneal, mid-foot B. COMMUNICATOR As Communicators, Orthopedic Surgeons effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. 1. Develop rapport, trust, and ethical therapeutic relationships with patients and families 1.1 Recognize that being a good communicator is a core clinical skill for physicians, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence and improved clinical outcomes 1.2 Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy 1.3 Respect patient confidentiality, privacy and autonomy 1.4 Listen effectively 1.5 Be aware and responsive to nonverbal cues 1.6 Facilitate a structured clinical encounter effectively 2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals 2.1 Gather information about a disease, but also about a patient s beliefs, concerns, expectations and illness experience 2.2 Recognize the emotional stress for patients and families faced with orthopedic conditions 2.3 Seek out and synthesize relevant information from other sources, such as a patient s family, caregivers and other professionals 3. Convey relevant information and explanations accurately to patients and families, colleagues and other professionals 3.1 Deliver information to a patient and family, colleagues and other professionals in a humane manner and in such a way that it is understandable, encourages discussion and participation in decision-making 3.2 Demonstrate cooperation and communication between health professionals involved in the care of individual patients such that consistent messages are delivered to patients and their families 6
4. Develop a common understanding on issues, problems and plans with patients, families, and other professionals to develop a shared plan of care 4.1 Identify and explore problems to be addressed from a patient encounter effectively, including the patient s context, responses, concerns, and preferences 4.2 Respect diversity and difference, including but not limited to the impact of gender, religion and cultural beliefs, socio-economic status, relevant family medical history, cultural norms of health promotion in urban and rural individuals and the expectations of patients and families, on decision-making 4.3 Encourage discussion, questions, and interaction in the encounter with patients and appointed representatives 4.4 Engage patients, families, and relevant health professionals in shared decisionmaking to develop a plan of care 4.5 Address challenging communication issues effectively, such as obtaining informed consent, delivering bad news, and addressing anger, confusion and misunderstanding of medical principles in a manner that respects cultural differences. 4.5.1 Obtain informed consent for surgical procedures, appreciating alternative means of achieving consent if the patient is unable to provide consent, on the grounds of age, mental status language or cultural barriers or other disqualifiers 5. Convey effective oral and written information about a medical encounter 5.1 Maintain clear, concise, accurate and appropriate records (e.g., written or electronic) of clinical encounters and plans 5.2 Present verbal reports of clinical encounters and plans effectively 5.3 Present medical information effectively to the public or media about a medical issue 6. Ambulatory Care Experience 6.1 Recognize the diversity of patients in the community, using language that is culturally sensitive, that respects the patient and family value systems. C. COLLABORATOR As Collaborators, Orthopedic Surgeons effectively work within a healthcare team to achieve optimal patient care. 1. Participate effectively and appropriately in an interprofessional healthcare team 1.1 Describe the specialist s roles and responsibilities to other professionals 1.2 Describe the roles and responsibilities of other professionals within the health care team 1.2.1 Describe community support groups which can assist the orthopedic patient and their families 1.3 Recognize and respect the diversity of roles, responsibilities and competences of other professionals in relation to their own 1.3.1 Recognize the limitations of their professional competence 7
1.4 Work with others to assess, plan, provide and integrate care for individual patients (or groups of patients) 1.4.1 Work effectively as a team member when not in a team leadership role 2. Work effectively with other health professionals to prevent, negotiate, and resolve interprofessional conflict 2.1 Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team 2.2 Work with other professionals to prevent conflicts 2.3 Employ collaborative negotiation to resolve conflicts 2.4 Respect differences and address misunderstandings and limitations in other professionals 2.5 Recognize one s own differences, misunderstanding and limitations that may contribute to interprofessional tension 3. Ambulatory Care Experience 3.1 Develop a care plan for a patient they have assessed, including investigation, treatment and continuity of care, in collaboration with members of the interdisciplinary team, the patient and the family 8