"Enclosed in this letter you will find"
1 of 10 STANFORD UNIVERSITY MEDICAL CENTER LUCILE SALTER PACKARD CHILDREN’S HOSPITAL AT STANFORD ROBERT A. CHASE HAND & UPPER LIMB CENTER 770 Welch Road Suite 400 Palo Alto, CA 94304 p: 650.723.6796 f: 650.723.6786 AMY L. LADD MD Chief, Chase Hand Center & LPCH Hand & Upper Limb Clinic Professor of Orthopaedic & Plastic Surgery Stanford Hand Fellowship Director Course Director, Anatomy of Movement http://move.stanford.edu email: firstname.lastname@example.org 1 July 2011 Dear Doctors: Welcome to the Rotation of the Stanford Hand & Upper Limb Center. Enclosed in this letter you will find detailed information about the service, including Goals and Objectives and logistics and reference information. Please read it carefully and refer to it as needed. Goals and Objectives The goal of the hand and upper limb rotation is to provide a breadth of experience and exposure to disorders affecting the hand and upper limb. The Stanford Hand and Upper Limb Center represent the most comprehensive interdisciplinary program in the country of its kind. A core curriculum is used, based on the core hand and upper limb textbook provided to you from the Edward Kim Memorial Book Fund. Currently we are using Trumble’s Hand, Elbow, Shoulder: Core Knowledge in Orthopaedics. For more detailed Shoulder and Elbow reading, recommended textbooks include Morrey’s The Elbow and Its Disorders and Rockwood and Matsen’s The Shoulder. This is augmented by selected readings and conference topics as chosen by the faculty and fellows. Goals and objectives for the resident are: 1) Medical Knowledge: Obtain knowledge and comprehension of the basic disorders that afflict the upper limb, and gain insight into the methodology and procedures incorporating its treatment. Particular emphasis is placed on the importance of interdisciplinary approach. Interpreting information obtained from a history and physical examination, incorporating data from radiology and laboratory studies, understanding anatomy, and incorporating this knowledge into surgical skills for hand and microsurgery is fundamental to the required knowledge. Soft tissue handling, microvascular environment of the limb, and pathology of systemic disease processes are as essential as learning the indications for surgery and the type of fixation chosen. Patient Care: Obtain acumen in diagnosing and proposing treatment in the clinical setting, and analyze available information to make diagnostic and therapeutic decisions based upon sound clinical judgment, best available evidence, and patient preferences. Perform at an upper resident level in surgical techniques pertaining to soft tissue, nerve, skeletal structures, and microsurgical procedures. The resident will participate in self- evaluation and improvement in the microsurgery lab for surgical skills. 2) Interpersonal and Communication Skills: Demonstrate the interpersonal skills and professionalism necessary to adequately diagnose and treat a variety of traumatic and elective hand injuries and disorders. This reflects the behavior of a role model to peers, junior residents, Hand & Upper Limb Rotation Overview 2010-11 2 of 10 and medical students. Demonstrate courtesy and timeliness with patient, family, and professional interactions. 3) Professionalism: Demonstrates respect, compassion, integrity, and honesty as it relates to patient interaction. Takes initiative in addressing the needs of patients and peers; acknowledges and addresses errors, and pursues self-improvement. 4) System-Based Practice: Demonstrate competence and ability to interact with outside institutions in the timely transfer and decision making process for traumatic hand injuries, and utilizes resources such as the Transfer Center in the emergent care of amputated digits at outside hospitals. Interpret and apply techniques and protocols in conjunction with hand, physical, and occupational therapy as it relates to patient care and management. Utilize and synthesize outside resources ranging from Lane Library and its wealth of older primary sources, Lane’s online resources, professional online resources (American Academy of Orthopaedic Surgeons, American Society of Surgery of the Hand, American Association of Hand Surgeons), pubmed, and other educational opportunities which enrich the clinical and academic education of the resident. 5) Practice-Based Learning and Improvement: Investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents on the hand rotation are expected to: a. analyze practice experience and perform practice-based improvement activities using a systematic methodology b. locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems c. obtain and use information about their own population of patients and the larger population from which their patients are drawn d. apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness e. use information technology to manage information, access on-line medical information; and support their own education f. facilitate the learning of students and other health care professionals Each of the above will be assimilated into the clinical, surgical, and scholarly activities as the rotation unfolds. Faculty Our faculty and our Hand & Upper Limb service are interdisciplinary, representing two departments: Plastic Surgery in the Department of Surgery, and the Department of Orthopaedic Surgery. Our current faculty members across the hand, shoulder, and elbow service are Dr. Hentz, Dr. Chang, Dr. Yao, Dr. Curtin, Dr. Sen, and myself. Dr. Hentz is the former chief of hand and plastics, and a stalwart Stanford luminary, with expertise in areas including brachial plexus, quadriplegic hand, and arthritis. Dr. Chang is the chief of plastics at Stanford and the VA, trained at Stanford and took his hand fellowship at UCLA. Dr. Yao trained in orthopaedics at Einstein in NY and took his hand fellowship at the Philadelphia Hand Center. Dr. Curtin trained at U Michigan in plastic surgery and completed our Stanford hand and upper limb fellowship in 2007. She is based primarily at the VA with weekly clinic and OR at the university. Dr. Robert Chase, the founder of our program, is emeritus but is busy with Anatomy and other hand-related projects when he visits from the East Coast, where he has now retired. Dr. Chase is also the former Chief and Chairman of Surgery, and the former Chief of Anatomy. Our newest faculty member is Dr. Subhro Sen, who trained at Indiana and Johns Hopkins and finished our Hand fellowship in 2009, and is now an Hand & Upper Limb Rotation Overview 2010-11 3 of 10 Instructor in Plastic Surgery and Microsurgical Reconstruction. Our Hand fellows 2010-11 are Dr. Andrew Zhang, having completed Plastic Surgery at Stanford, and Adam Wilson, having completed orthopaedic surgery at Robert Wood Johnson Medical School in NJ. In August 2011 Shari Liberman from Texas and Rosie Sendher from Toronto will join us. Dr. Cheung and Dr. Costouros are our shoulder and elbow faculty. The orthopaedic residents will receive information from them about the service. Additional attendings and fellow who share hand call and participate in academic activities are as follows. Dr. Gordon Lee leads the microsurgical service, and joined the plastic surgery faculty after training at UCLA and completing a microvascular fellowship at MD Anderson. Two new microvascular fellows will also start 1 August 2011. Dr. Andrew Gutow is an orthopaedic hand surgeon at the Palo Alto Medical Foundation who also takes call with us. Dr. McAdams cares for sports upper extremity injuries, and may work occasionally with the fellow. Clinics Stanford: Stanford Clinics are held at 450 Broadway Pavilion A 2nd floor in Redwood City. See the grid for attending schedules at the end of this letter for a simplified version of our schedules. Note these will vary somewhat depending on people’s travel and leave time. Clinic notes are dictated on the Stanford phone system (our clinic code for Stanford is “99” (Ortho) or “65” (Plastics) and the clinic code for Packard is “77.”) Since we are charged by the word, this is a good opportunity to dictate short and precise notes. Stanford requires that all documents meet HCFA requirements for Medicare reimbursement, which means that all charges must be substantiated by documentation in a format that is outlined on the encounter form. We will review this with you. Specifically, a patient is charged a level of service (an E & M code), and is designated a diagnosis (an ICD 9 code). Letters to worker's compensation insurance carriers additionally require date of injury, worker's comp claim number, employer, disability status of the patient, estimated return to work, assessment if patient is deemed a "qualified injured worker," as well as whether he or she is "permanent and stationary." The specific format is posted in the clinic. The attending will reinforce these dictations. All procedures (casts, injections, dressing changes) performed in the clinic are billed with a CPT code, as are supplies. Becoming facile with choosing diagnoses (ICD-9 codes) and procedures (CPT codes), will assist your ability to track cases, as is necessary for the AAMC/ Residency Review Committee mandates. Each of us typically chooses the CPT codes at surgery, so make it a habit of entering your cases the day of surgery. Medical students, visiting students and faculty, and other visitors frequently join us for the office and operative experience. Please assume a teaching role when appropriate. Palo Alto Veteran's Affairs: Dr. Hentz, Dr. Chang, and Dr. Curtin share coverage of the VA for general hand, and Dr. Hentz for Spinal Cord Injury clinic of the upper extremity. The VA Hand clinic meets Wednesday mornings. Lucile Salter Packard Hand Clinic: We see pediatric hand and upper extremity problems, typically congenital problems and trauma at 730 Welch Road. Dr. Chang and I alternate Wednesday mornings. Dr. Hentz sees obstetrical palsy patients the first Monday of each month. Operating room Hand & Upper Limb Rotation Overview 2010-11 4 of 10 We operate in one of four ORs: Main OR, ASC, and LPCH at Stanford, and OSC at Redwood City. Check your schedule carefully for your assignment and call the day before to confirm if necessary. Each attending has an orthopaedic or plastic flavor to his or her practice, and the natural tendency is to seek out the cases pertinent to your discipline. Keep in mind, however, you need to spend clinic and operative time with each attending for your optimal experience, and for fair assessment of your performance—this is not optional. Even though you may have little long-term interest in a microvascular case, or a shoulder arthroscopy, there are principles and anatomy to be learned at a more fundamental level from most cases. You may expect to be the primary surgeon for cases commensurate with your training and skills, provided you have performed the expected tasks. These include reading about the case, becoming familiar with the anatomy and different surgical options, and the ability to field questions in the operating room. And importantly, these include the menial tasks of ensuring that the workup is complete, X-rays are obtained, you arrive early (7:00 or earlier) to mark and assist the patient in the room (so the case starts at 7:30), and the patient and tourniquet are positioned. The converse is also true: if the expected work is not done, do not expect to do the case. The cliché of working as a team indeed applies. The faculty is more receptive to your performing the procedure if you know the patient and are familiar with the decision making process. One resident will attend one surgeon for the given OR day. Switching residents for different cases is not allowed, although the fellow may do so. In general, you should make every effort to attend clinics with an attending the same week you will be in the OR with him/her, since preop patients often come in the same week. This is particularly true with our Packard population. Weekly schedule The fellows are responsible for making the weekly duty schedule, which will be emailed out every weekend. The fellows have been instructed by me to be as fair and equitable as possible in the distribution of assignments between the residents and fellows. Understand however that there may be weeks in which you may have more clinic or OR duties. Rest assured that everything almost always even out over the rotation. If you have any special interests or if you have worked up a patient and want to participate in that case, be proactive and let the fellows know. Rounding Each resident will follow his/her own inpatients/consults on the service and communicate with the respective attending daily. Given that we are spread out at multiple sites, sometimes you may need some planning and foresight re: discharge paperwork, orders, etc. Fellows will also follow their own inpatients; in rare cases they may ask you to do something for their patients if they are at the VA, away for the weekend, etc. The resident-on-call will round on the entire service over the weekend. Microvascular training Microvascular training is available to you through the skills laboratory in the Anatomy area of the Surge II Building. The fellows will also organize several microsurgical skills lab throughout the year. You will be expected to attain a certain competency in microsurgical skills prior to the start of the rotation (handling micro-instruments, manipulating tissue under the microscope, basic micro- suturing techniques) so that you can be an effective assistant in replantation cases when you are on call. Hand & Upper Limb Rotation Overview 2010-11 5 of 10 Emergency Department (ED) Please be prompt in returning ED pages. In general, during the day emergency pages are directed to the on-call resident. In general, we will try to schedule the on-call resident to a Stanford University assignment if possible. If you receive an emergent ED call and you are at the Redwood City site, you can try to triage the call over the phone if medically appropriate, or you can see if there is any Hand resident or fellow at the University who may be able to triage the patient for you. If the ED patient needs to be seen right away, and no one else is available, politely request permission from the attending you are with to be excused so you can travel back to Stanford to evaluate the patient. If medically appropriate, you can also ask the ED physician to stabilize the injury and send the patient to Redwood City to be evaluated. Discuss the case (if necessary) with the attending you are in clinic or in the OR with first, not necessarily the surgeon on call. Priority goes next to the attending on call, and then finally to the person who is most available. Calls after 5 pm should be discussed with the attending on call directly. Replantation calls and transfers that you receive should be referred to the attending on call, who makes the final decision to accept or decline the patient’s admission. If you are on call over the weekend, you must identify all new patients to our new patient coordinators in the hand clinic (direct # is 498-7555 or voicemail 721-3593) and our medical assistants (721-7745). Call or leave a message with new patient line or the MA no later than 8:30 on Monday. This permits them to obtain insurance info, authorization, x-rays, and get the patient scheduled in a timely fashion to streamline the clinic flow. Update the fellows on any add-on cases during the week so that they can schedule appropriate coverage for the cases. Call Your call is every 3rd night (q3), to be shared equally between the two orthopaedic residents and the plastics resident. All calls are “home-calls,” and we abide by the 80-hour work week required by the ACGME. The two hand fellows and the micro fellow share in a separate fellow call schedule. Thus, on a given day, the call team will comprise of a resident taking first call, a fellow on second call, and an attending. During call, the fellow serves as your “back-up,” acting as the intermediary between you and the attending and assisting you in decision-making and patient care. A word of caution: there are times when hand call gets really busy, and it is not uncommon to have several all-night replantation cases on busy weeks. We strongly recommend that you avoid designing your call schedule with one person taking large blocks of contiguous days of call (“power weeks”). Fatigue can set in quickly in a busy call week, and may affect your performance and endanger patient care. I reserve the right to edit your call schedule if we think that it will create an unsafe environment for you and our patients. Continuity of care It is your responsibility to contact your fellow resident on the weekend before start of your rotation and get a detailed sign-out of the service and the respective in-patients your fellow resident covers. On the first day of the service, you will be responsible for rounding on those patients and assuming their full care. I recommend on your first day to contact the attendings involved and update them on Hand & Upper Limb Rotation Overview 2010-11 6 of 10 their patients, both as a way to introduce yourself to them and so they know that transfer of care has taken place and their patients are appropriately cared for. It is mandatory that each Friday, every resident and fellow must email a sign-out of all inpatients (including weekend/discharge plans, issues, etc.) to ALL of the service residents and fellows. Please cc: the micro fellow the weekends he/she takes call. Even if you don't have any patients, please email that fact as well, to close the loop. A telephone call to the on call resident is also appreciated. Office location and staff The primary resident and fellow office resides at 450 Broadway Building (SMOC) Pavilion C 4th floor; Donna San Juan is my administrative assistant and the fellowship program coordinator (650.721.7626). The plastic attendings and my office are located at 770 Welch Road, Suite 400. Dr. Cheung and Dr. Yao have primary offices at SMOC, and each of us has a satellite office there, including the fellows and residents. Meet and get to know each of our staff, for they will make life easier for you. Patti Green (721- 7777) oversees all the clinics, and works closely with the Hand Center. Gina Presby is our primary surgery scheduler at 721-7743. Dr. Yao’s and Dr. Cheung’s scheduler is Catherine Versosa (721- 7741). We are transitioning medical assistants (MAs) in August 2011; currently their main # is 721- 7745. The new patient line for the hand/upper extremity clinics is 498-7555. Please leave a message (off hours) or call to leave information about ED patients who need to be scheduled in the hand clinic, including post-weekend call for Monday morning. This will save time and effort on everyone’s part, and establish insurance aspects of the future visit. Education Monday Preop Conference Monday morning preop conference takes place at the C-400 conference room at 450 Broadway. It begins with a chalk talk or Hand Self-Assessment Question review led by the fellows with the residents (7:00-7:30), and then pre-op conference (7:30-8:30) in which the weekend cases as well as the upcoming cases for the week will be discussed. You will be responsible for presenting pertinent OR cases you are assigned to that week. This involves being familiar with the history and exam of your patient and the findings on any imaging studies. Be prepared to discuss the indications of the surgery, general surgical approaches and your surgical plan, and postoperative rehabilitation for the case. The resident-on-call over the weekend will print out the H&P of all cases for the following week for the conference. Wednesday Hand Conference Teaching conferences are held primarily Wednesday afternoon at 4 pm at 770 Welch Road, with one or two times a month rotating to our l SMOC facility. Conferences will concentrate on traditional lectures and journal club. We follow a Curriculum with core topics in hand surgery, rounded out by interest and experience. Anatomy labs, and industry sponsored cadaver and saw bones labs will be held after Wednesday conferences or on other days. Each of you will present a topic of your choice at one of the Wednesday afternoon conferences before the end of the rotation. Topics of interest or desired research are pertinent. You may do this at any time; most residents present during the end of their rotation. To avoid repetitions of topics Hand & Upper Limb Rotation Overview 2010-11 7 of 10 please plan this talk accordingly and clear your proposed topic with me at least two weeks before your presentation. The attendings are reminded to release residents from clinical duties to attend Grand Rounds (Ortho Wed morning 6:30-9:00 am, Plastics Tues 4:30 pm) and Wednesday hand conference. If you are in the OR or in clinic, politely ask to be excused. Very important: let me know if problems arise. Journal Club Journal Club will be held approximately every two months. Articles to be discussed will be distributed by the fellows about a month in advance. You are responsible for reading ALL the articles and being able to present each one if asked. Fellowship The Residency Review Committee through the ACGME accredits our hand fellowship, which means the residents and fellows must meet the same expectations and documentation as determined by the ACGME, including core competencies and 360 degree evaluations. The fellows serve as a liaison for the attending faculty and the residents. The resident experience is of paramount importance even with the addition of the fellows. Part of the fellows' responsibility is to ensure that this resident experience remains the central focus. Thus the fellow will assume the role of a junior faculty in surgical cases: she/he may attend the case, but will assist or perform the case depending on the resident's capabilities, level of involvement, and the complexity of the case. The fellow will take an active role in the education during the hand rotation by organizing and occasionally giving conferences, giving resident chalk-talks, arranging microsurgical labs and anatomy dissection. Our library at Welch Road is quite complete for hand textbooks, monographs, abstracts and proceedings, as well as journals covering the hand and upper limb which pre-date electronic publications. These represent our personal collections. If you wish access to them, please let me know. Do not remove books or journals from the library. We have a copier in our Welch Road office available to you. Responsibilities Many of your responsibilities on the hand rotation are analogous to other surgical rotations in orthopaedic, plastic, or general surgery, but also reflect your upper level residency status. You are given more responsibility and therefore independence, commensurate with your knowledge and ability. Suggestions for handling patients and situations in the clinic, operating room, and emergency room would be the following. If you are the first physician to see a new patient in the clinic setting, take a complete history, thorough examination of the upper extremity (and neck if indicated), and formulate a differential diagnosis and treatment plan. Similarly, prepare for the operating room with a surgical plan and alternative plans; even if yours is not the chosen course of action, you will have engendered a reasonable discussion. Such an approach will serve you well in the emergency room. Although we need to hear directly about any emergencies or treatment problems, you will often be making decisions and handling situations in the emergency room in this fashion. Hand & Upper Limb Rotation Overview 2010-11 8 of 10 Please keep a list of your involvement in all operative cases; designated as inpatient or outpatient procedures, and a list of complications. You need to submit this for ACGME documentation, as you know, but you will also need to compile a list for quality assurance (a.k.a. morbidity and mortality) for each of the respective disciplines, plastics and orthopaedics. In the past, the resident submitted complications that he or she participated in, to the parent specialty, eg plastics or orthopaedics. For Quality Assurance rounds, you must now identify the attending as plastics or orthopaedics, and have the resident for the particular specialty present the complication accordingly. Although this is not ideal, it potentially cuts down on the possibility of double reporting a complication to 2 different departments. Interesting cases, however, can be presented to either specialty’s grand rounds. Please be timely in your MedHub case logs and work hours submissions, as well as completing Evaluations of the faculty and program. Research Dr. Hentz, Dr. Chang, Dr. Yao, Dr. Cheung, Dr. Curtin, Dr. Sen, and myself have many current research projects, and will be able to provide information for you. My current areas of interest focuses on thumb CMC arthritis, high-resolution anatomy imaging, motion analysis of the upper limb, congenital anomalies, distal radius fractures, malunions, and osteoporotic fractures. Vacation Please arrange ahead of time with us if you plan to be away. All vacation requests are approved on a “first-come first-serve” basis and should be submitted to the fellows and I at least one month PRIOR to the start of the rotation. Only one resident or fellow will be allowed off the service at a given time. We allow no more than 5 weekdays off (7 days total including the adjacent weekend) on the Hand rotation. Since we are now operating at multiple sites, there are days when our team is stretched very thin. Thus, your vacation may be taken only on weeks when an attending is away to minimize disruption to the service. This will require advanced coordination, so please plan and ask early. Donna San Juan have a schedule of when attendings will be off; check with her before submitting your vacation requests. I understand that on rare occasions, personal or professional emergencies may arise. I will assess and approve time-off in these situations on a case-to-case basis. Welcome! I trust this letter is useful to you in the next few months—keep it close at hand as a reference for phone numbers and reference. Again, welcome. Sincerely, Amy L. Ladd, M.D. Professor, Robert A. Chase Hand & Upper Limb Center Hand & Upper Limb Rotation Overview 2010-11 9 of 10 cc: Dr. Hentz Dr. Chang Dr. Yao Dr. Cheung Dr. Curtin Dr. Maloney Dr. Krummel Dr. Chase Dr. Lee Dr. Sen Dr.Wilson Dr. Zhang Dr. Costouros Hand Surgery Staff Plastic Surgery Staff Hand & Upper Limb Rotation Overview 2010-11 10 of 10 ATTENDING SCHEDULES incomplete AM/ Monday Tuesday Wednesday Thursday Friday PM CHANG AM Clinic 8:00 8:30 VA clinic or OSC/ASC OR 9:00 LPCH Clinic ASC OR VA OR/LPCH OR (alternating) (1x/mo) PM Admin Research HENTZ AM Admin/Research VA clinic 8:30 ASC OR OSC OR VA OR PM OSC Clinic 1:00 p VA SCI clinic LPCH BP clinic (1x/mo) 1st Monday LADD AM OSC OR 9:30 LPCH clinic or OSC Clinic 8:00 Adult new patient LPCH OR vs admin ASC OR vs. Admin OSC clinic (alternating) PM OSC OR Admin/Research/M akeup clinic YAO AM Clinic 8:00 PM Clinic9:00 OSC OR Admin/Research OSC OR CHEUNG AM Clinic 9:00 Main/ASC OR Clinic 8:00 OSC OR Stanford OR Admin/Research Ortho Gr Rounds/ Admin Training Room Stanford OR PM Stanford clinic Research Stanford Clinic CURTIN AM/ PM OSC/ASC OR VA clinic 8:30 Clinic 8:00 VA OR SEN 6) Hand & Upper Limb Rotation Overview 2010-11