The University of Texas-Houston Medical School by tlyaappjdlag

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									      The University of Texas Medical School at
                       Houston
               TRANSITIONAL YEAR PROGRAM MANUAL



                                   2010-2011




                              Christine E. Koerner, MD
                                 Program Director

                                   Debbie Tabor
                                Program Coordinator




Participating Hospitals:
       Lyndon B. Johnson General Hospital
       Memorial Hermann Hospital
       UT MD Anderson Cancer Center




                                            1
Welcome to the Transitional Year Program! You are at the beginning of what will be a
challenging and rewarding first post-graduate year. The Transitional Year Program is a fully
accredited program as reviewed by the Accreditation Council for Graduate Medical Education.
The Program is conducted consistent with the ACGME Institutional and Program Requirements
for the Transitional Year.

In conjunction with our sponsoring departments of Internal Medicine, Pediatrics, and Surgery, we
will provide training that focuses on education and patient care in an environment that is
conducive to learning, which ensures that undue stress and fatigue are avoided, and in which
service obligations of our teaching hospitals are secondary to your education. The main goal of
the Transitional Year is to give you a solid foundation in the fundamental clinical skills of
medicine that will prepare you for specialty training. It is a strong principle of this program that
Transitional residents are afforded educational opportunities that are equivalent to those provided
to first-year residents in our sponsoring departments.

Your education will be accomplished through multiple means: hands-on patient care which will
be carefully supervised by faculty and residents more-senior than yourselves; conferences such as
Grand Rounds and Mortality & Morbidity Conference at which your attendance is required and
will be documented; performance evaluations which will be reviewed with you by your faculty
attending and by me as your Program Director.

You will have a voice in the conduct of this year. Just as faculty will evaluate you, you, in turn,
will be asked to evaluate each rotation and each faculty member under whose supervision you
train. Your feedback helps us to assure that the goals of this program are met. Should a
circumstance occur in which you experience a violation of the policies and procedures as set out
in this manual, it is your responsibility to bring that circumstance to our attention. Additionally,
one member of your class (and an alternate) will be elected to serve as your representative on the
Transitional Year Education Committee, which governs this program. At each quarterly meeting
of the TYEC, your representative will bring your concerns and comments to the Committee.
You are encouraged to make use of this resource.

This manual is intended to be your guide to the practical aspects of the Transitional Year
Program at the University of Texas Medical School at Houston. The manual supplements the
residency web site (http://www.lbj.uth.tmc.edu/Resid_new.htm) and The Graduate Medical
Education Trainee Handbook. You are encouraged to review the information contained and to
keep this manual at hand as the year progresses.

Congratulations on taking this first step in your graduate medical education. We look forward to
working with you and to getting to know you better as the year progresses.


                                                             Christine E. Koerner, MD
                                                             Program Director

                                                 2
                THE OATH OF HIPPOCRATES


I    do solemnly swear, by whatever I hold most sacred:

That I will be loyal to the profession of medicine and just and
 generous to its members;

That I will lead my life and practice my profession in uprightness
 and honor;

That into whatsoever house I shall enter, it shall be for the good
 of the sick to the utmost of my power, holding myself far aloof
 from wrong, from corruption, from the tempting of others to vice;

That I will exercise my profession solely for the cure of my
 patients, and will give no drug, perform no operation, for a
 criminal purpose, even if solicited, far less suggest it;

That whatsoever I shall see or hear of the lives of men which is not
 fitting to be spoken, I will keep inviolably secret. These things do I
 swear.

And now, should I be true to this, my oath, may prosperity and good
repute be ever mine, the opposite, should I prove myself forsworn.




                                  3
                            TABLE OF CONTENTS
OBJECTIVES                                      7
TRANSITIONAL YEAR PROGRAM OFFICE                7
Institutional Permit/Licensure                  8
Advanced Cardiac Life Support                   8
Supervision                                     8
Evaluations and Personnel Files                 8
Electronic Resources                            9
Vacation Time                                   9
Sick Time                                       10
Other Benefits                                  10
Employee Assistance and Work/Life Program       10
Military Leave                                  10
Leave of Absence                                10
Duty Hours                                      10
Ambulatory Hours                                11
Risk Management Education                       11
Professional Medical Liability Coverage         11
Sexual Harassment Policy                        11
Completion of Training Check-Out                12
AFFILIATED HOSPITALS                            13
LBJ GENERAL HOSPITAL COURTESIES                 14
Office of the Chief of Staff                    14
Provider Number                                 14
Pagers                                          14
Pager Batteries                                 14
UT/LBJ Access Key Card                          14
Lockers                                         14
Parking                                         14
Uniforms                                        15
Scrub Suits                                     15
Call Room Keys                                  15
On Call Meals                                   15
Cafeteria Hours                                 15
Libraries                                       15
Lounges                                         15
Internet Access                                 16
Security                                        16
HERMANN HOSPITAL COURTESIES                     17
House Staff Affairs Office                      17
Pharmacy ID Number                              17
Pagers and Paging                               17
Pager Batteries                                 17

                                      4
Lockers                                                               17
Parking                                                               17
Scrub Suits                                                           17
Call Rooms                                                            17
Meal Tickets                                                          17
Cafeteria Hours                                                       17
Libraries                                                             18
Lounge                                                                18
Security                                                              18
THE UNIVERSITY OF TEXAS M.D. ANDERSON CANCER CENTER (MDA)             19
Orientation                                                           19
I.D. Badge                                                            19
Library                                                               19
Computer Access                                                       19
Food Services                                                         19
Parking                                                               19
SPONSORING DEPARTMENTS                                                20
Goals and Objectives of the Transitional Year Program                 21
GOALS AND OBJECTIVES OF THE CLINICAL ROTATIONS                        22
LBJ General Medical Services A-D                                      23
Memorial Hermann General War Services A-D                             27
LBJ Ambulatory/Memorial Hermann Ambulatory Block Rotation             31
LBJ Medical Intensive Care Unit                                       35
Memorial Hermann Medical Intensive Care Unit                          40
MHH Coronary Care Unit (CCU) and Cardiology Ward Unit                 45
MHH and LBJ Renal Inpatient Service                                   49
M.D. Anderson Hematology Consultation Service                         54
LBJ Emergency Medicine and LBJ Emergency Center                       59
General Surgery LBJ Hospital                                          64
General Surgery MHH                                                   77
Pediatric Surgery – MHH and M.D. Anderson Cancer Center               91
Surgical Critical Care – MHH                                          101
Burns Surgery – MHH                                                   118
Plastic Surgery – MHH                                                 126
Surgical Immunology and Transplantation Service – MHH                 137
Neurosurgery                                                          144
General Inpatient Pediatric Rotation                                  149
Pediatric Emergency Medicine and Ambulatory Acute Illness Rotations   161
Pediatric Neonatal ICU Rotation                                       173
Pediatric Pulmonology Rotation                                        179
Pediatric Nephrology Rotation                                         185
Ophthalmology Elective                                                191
Orthopaedic Internship Rotation                                       196
Duke Trauma Service – MHH                                             201

                                     5
Dermatology Elective                                              209
Neurology Elective                                                212
Pathology Elective                                                216
Appendix 1 – Policies of the Transitional Year Program            220
Eligibility of Residents                                          221
Selection of Residents                                            221
Policy on Resident Duty Hours                                     222
Policy on Resident Supervision                                    223
Policy on Resident Corrective Action, Complaints and Grievances   224
Academic and Corrective Action                                    224
Additional Corrective Actions                                     224
Dismissal                                                         224
Policy on Resident Well Being                                     225
Policy on Resident Moonlighting                                   226
Policy on Evaluation, Termination and Resignation of Residents    227
Evaluation of Residents                                           227
Termination of Residents                                          227
Resignation                                                       227
Grievances                                                        227
Policy on Conference Attendance                                   229
Policy on Use of Vacation Time                                    230
Policy on Additional Leave for Health Related Reasons             231
Policy on Use of Pagers and Electronic Communications             232
Pagers                                                            232
Electronic Mail                                                   232
Policy on Use of Personal Digital Assistant                       233
Equipment                                                         233
Use of PDA                                                        233
Policy on Appropriate Student Treatment                           234
Standards for Conduct in the Teacher-Learner Relationship         234
Dissemination and Education                                       236
Appendix 2 – Evaluation Forms                                     237
Useful Telephone Numbers                                          240
Acknowledgement of Receipt of Manual                              242




                                           6
 OBJECTIVE OF THE TRANSITIONAL YEAR
The broad objective of the Transitional Year Program is to provide qualified medical school
graduates with a year of fundamental clinical education in multiple disciplines to facilitate the
choice of and/or preparation for a specialty. Residents will develop skills necessary to obtain a
complete medical history; perform a complete physical examination; define a patient's problems;
develop a rational plan for diagnosis; implement therapy based upon the etiology, pathogenesis
and clinical manifestations of various diseases; and develop humane qualities that enhance
interactions between the physician, the patients, and the patients’ families. A resident should
expect to develop mature clinical judgment through patient care, well-documented record
keeping, order writing and continuing management commensurate with his/her ability. These
skills will reflect the general competencies as defined by the Accreditation Council for Graduate
Medical Education, namely: patient care, medical knowledge, practice-based learning and
improvement, interpersonal and communications skills, professionalism, and systems-based
practice.

CURRICULUM
The duration of the transitional year is 12 calendar months. The year consists of: a 5-month
major and 3 one-month selectives chosen from among Internal Medicine, Pediatrics, Surgery and
OB-GYN; two one-month electives; one month of adult emergency medicine; one month of
combined adult/pediatrics emergency medicine. These choices are made in consultation with the
Program Director and are determined by the educational needs of the individual resident.

Goals and objectives for these rotations are included in this manual beginning on page 21.
Additionally, goals and objectives are available on-line through Black Board (see page 9 of this
manual for access instructions). It is important that you review these electronic versions as
changes may have occurred compared to any printed copies. Residents can expect to receive
goals and objectives at the start of each rotation from the TY Residency Coordinator. Residents
will also receive the goals and objectives receipt, which should be signed by both the attending
physician and TY resident to confirm that the goals and objectives for the rotation were
reviewed. This receipt should be returned to the TY Residency Coordinator or by specified date
indicated. The curriculum will include discussions of moral, ethical, legal, social, and economic
issues, as well as the general competencies of patient care, medical knowledge, practice-based
learning, interpersonal and communication skills, professionalism, and systems-based practice.

TRANSITIONAL YEAR PROGRAM OFFICE
This office is located within the Chief of Staff Office of the Lyndon B. Johnson General
Hospital, room COS 101. It is on the first floor of the hospital, the same hallway as the cafeteria
and across from the employee cashier’s office. Debbie Tabor is the Residency Coordinator.
Please inform the office in case of any emergency, illness, absence from rotation or other matters
relating to the program as soon as possible, or at the latest within 24 hours of the occurrence
(phone:713-566-4658). Office hours are 7:30 AM to 5:00 PM, Monday through Friday; an
answering machine is used to collect messages after hours. Transitional residents’ mailboxes are
located in this office. Should immediate attention be needed please call Christine Koerner
Program Director at (cell: 832-723-7752, or office 713-566-5775).

                                                 7
INSTITUTIONAL PERMIT/LICENSURE
Transitional year residents are required to possess an Institutional Permit issued by the Texas
State Board of Medical Examiners prior to June 23. Renewal of this permit is the resident's
responsibility.

Should you choose to apply for permanent licensure in Texas near the completion of your
training, applications are requested from the Texas State Board of Medical Examiners, P O Box
2029, Austin, TX 78768-2029, Licensure Division, phone (512) 305-7018; fax (512) 305-7008 .
You can obtain more information about the State Board on the Internet at www.tsbme.state.tx.us/
.

ADVANCED CARDIAC LIFE SUPPORT (ACLS)
ACLS certification is required for all transitional year residents, and it is the resident's
responsibility to keep certification current. Courses are offered through the Hermann Hospital
Life Flight Office. Registration forms for the course can be obtained at the Life Flight Office,
Robertson Pavilion of Memorial Hermann Hospital, phone 713-704-6151.

SUPERVISION
Transitional year residents will receive direct and proper supervision on every rotation by a
faculty member and by a more-senior resident. While residents may be supervised by more-
senior residents, all patient care and resident supervision ultimately is the responsibility of the
faculty attending physician. The responsibility or independence given to the transitional year
resident by the supervising physician for the care of patients should depend on the resident’s
knowledge, manual skills, experience, the complexity of the patients’ illnesses, and the risk of
procedures that residents perform. (See Policy on Resident Supervision, page 223 of this
Manual).

EVALUATIONS AND PERSONNEL FILES
In compliance with the guidelines of the Accreditation Council for Graduate Medical Education,
the attending physician will evaluate each resident monthly. In the GMEIS system, on-line
evaluation forms are automatically sent to each faculty member in the last week of the month.
Simultaneously, an evaluation of the rotation is sent electronically to the resident, which allows
the resident to evaluate each monthly rotation for its effectiveness and quality of teaching. These
evaluations, as well as other personnel documents, are reviewed by the Program Director and are
kept on file by the Residency Coordinator. Residents may review their files at any time in the
presence of the Residency Coordinator.

The Program Director will meet with each resident four times during the year to review his/her
progress and will report the resident’s progress to the second year Program Director as required
by Resident Review Committee guidelines for each specialty. At the end of the year, the Program
Director will complete a written evaluation for each resident which will include a review of the
last quarter as required by Resident Review Committee guidelines, as well as the Program
Director’s assessment of the resident’s professional ability to advance into a categorical program.
 Refer to Appendix 2 of this Manual for the Program Director Quarterly Rating of Resident
Clinical Competence form which details how the resident is rated, when credit is given, and

                                                  8
when remediation might be indicated.

Prior to successful completion of the Transitional Year, the resident will be asked to complete a
year- end program evaluation form, which elicits responses about the Program as a whole. The
Transitional Year Education Committee, which governs the Transitional Year Program, will use
information obtained from these evaluations in planning the future of the Program.

Refer to Appendix 2 of this Manual for evaluation forms and details of the rating of clinical
competence.

ELECTRONIC RESOURCES
Transitional year residents are required to have a Personal Digital Assistant (PDA). To assist
each transitional resident in bedside information retrieval the TY Program will provide clinical
reference software. Please see the Policy on Personal Digital Assistant Usage (page 49 of this
Manual). A docking station is available in the Program Office and can be checked out from the
Residency Coordinator.

Internet access and e-mail user ID are provided through The University of Texas. Use of these
resources is limited to professional activities. Because of the use of electronic evaluations,
residents are required to have a University of Texas e-mail address and to use it in preference to a
private e-mail service for communication related to the training program. The UT e-mail service
may NOT be forwarded to a private e-mail service. Computers are provided throughout the
various hospitals for resident use.

An on-line educational system, BLACKBOARD can be accessed at https://bb.uth.tmc.edu/. E-
mail user ID and password are the resident’s access to the system. This system contains Goals
and Objectives of each rotation, links to a required lecture series, the Transitional Year Manual,
as well as scheduling and communication options.

Alphanumeric pagers are provided for each resident through Memorial Hermann Hospital.
Residents are required to carry their pagers at all times, except when on vacation, and are
required to respond to pages in the shortest time-frame possible.

VACATION TIME
By contract, Transitional residents are given 14 days of paid vacation leave. It is the policy of the
Transitional Year Program that this vacation may be scheduled over a maximum of two periods.
No vacation may be taken during elective rotations, emergency medicine, and some ward months
or during the month of June (beginning and ending of the academic year). Approved vacations
are published as part of the resident's rotation schedule. If a change to the published schedule
becomes necessary, the resident must make the request to the Transitional Year Program Office
by completing a Vacation and Leave of Absence Request form. A resident is not eligible to
accumulate annual vacation. A resident leaving the Program will not be compensated for unused
vacation. All requests are to be scheduled through the Transitional Year Program Office, not
through the office of a sponsoring program or by permission of an attending faculty member.
Any vacation request approved by someone other than the Transitional Year Program Director

                                                 9
will not be honored. (See Policy on Use of Vacation Time, page 230 of this manual).

SICK TIME
Paid sick leave accumulates at a rate of one (1) day (eight (8) hours) each month and accumulates
to a maximum of twelve (12) days for Transitional residents. Paid sick leave will not be
compensated upon separation. If a resident misses work days due to illness, s/he is required to
phone the attending faculty or senior resident, as well as the Transitional Year Program Office in
the morning of each sick day.

In the event an illness exceeds accumulated paid sick leave and vacation time, a leave of absence
without pay may be granted (see “Graduate Medical Education Resident Handbook”, Section
II.H.7)

OTHER BENEFITS
For information on other benefits, residents are referred to the “Graduate Medical Education
Resident Handbook”, Section II.H. Fringe Benefits, and to The UT System Medical Foundation
web site at http://utsmf.hsc.uth.tmc.edu/benefits.html .

EMPLOYEE ASSISTANCE AND WORK/LIFE PROGRAM
Residents are eligible to use both the Employee Assistance Program (EAP) and the Work/Life
Program. The Employee Assistance Program (www.uteap.org ) offers services to help residents
resolve problems in their personal lives that may affect performance in their Programs.

MILITARY LEAVE
When necessary, a resident will be granted a military leave of absence with full pay for annual
tours of duty or active duty during an emergency with the Texas National Guard, Texas State
Guard, or any of the reserve components of the armed forces. The maximum time for which a
resident may receive such pay is 15 working days. Residents who exhaust the 15-day period of
paid military leave and are called for additional military service will be put on extended military
leave in accordance with University policy.

LEAVE OF ABSENCE
Under special circumstances, a leave of absence may be granted by the Program Director.

DUTY HOURS
Each resident is required to submit duty hours every month. The resident will receive an
electronic notification through GMEIS to report his/her duty hours for the month. Reports can
then be generated by the Program Director or Program Coordinator.

AMBULATORY HOURS
Each resident is required to obtain 140 hours of documented experience in general ambulatory
care settings over a 12-month period, other than that acquired in the emergency department.
Outpatient experience must be obtained from general ambulatory rotations provided by Internal
Medicine, OB-GYN, Family Practice, Pediatrics or Surgery. The resident will receive an
ambulatory time sheet on which to document all ambulatory experience. This time sheet must

                                                10
be signed daily by the attending under whose supervision the ambulatory hours are
worked. It is important to accurately document all ambulatory hours, as a failure to obtain the
requisite 140 hours can have an impact on the successful completion of the Transitional Year.
Return the time sheet to the Residency Coordinator at the end of the month. In addition, daily
evaluation cards or “shift cards” are to be completed by each attending and returned to the
Residency Coordinator. For successful completion of this rotation, residents must turn in four H
& P’s for each discipline.

RISK MANAGEMENT EDUCATION
The University of Texas System mandates that all physicians complete 15 hours of risk
management education during their first eight months of employment with the University. For
the Transitional resident, this requires completion of a core course in medical-legal risk
management. This must be accomplished by January 31st. This requirement is handled via the
Internet at http://ut.elmexchange.com/ccc. Contact the Residency Coordinator for further
information.

PROFESSIONAL MEDICAL LIABILITY INSURANCE
Trainees are provided professional medical liability coverage through The University of Texas
System Professional Medical Liability Benefit Plan. The plan provides basic coverage of
$100,000 per claim; $300,000 annual aggregate. Causes of action that occur during official
University of Texas System employment are covered, even though a claim or lawsuit is filed
subsequent to cessation of employment. If a resident receives a notice of claim letter or is served
in a lawsuit regarding patient care, s/he is to contact the Transitional Year Program Office as well
as the University's Healthcare Risk Manager Catherine Thompson, RN, MPH. Ms. Thompson's
phone number is 713-500-3280.

SEXUAL HARASSMENT POLICY
The University of Texas Health Science Center at Houston (UTHSC-H) explicitly prohibits any
form of sex discrimination or sexual harassment by any member of the university community
against another member of the university community. Members of the community include
administrators, faculty, staff, students, residents, fellows, and patients, etc.

The university has charged the Department of Human Resources, Division of Equal
Opportunity, with the primary responsibility for educating the university community on
sexual harassment; counseling complainants; handling and processing complaints and
investigations; and reporting findings to the appropriate administrators. The phone
number is 713-500-3130. More information about this issue can be obtained on the
Internet at http://hr.uth.tmc.edu/EEOnew/about_eo.html.




                                                11
COMPLETION OF TRAINING CHECK-OUT
In order to receive your certificate for completion of training, the Transitional resident must
complete The University of Texas System Medical Foundation Resident Check-Out Form, as
well as the Harris County Hospital District Resident Check-Out Form. The forms will be
provided to you in your final month of training. It is the resident's responsibility to obtain
signatures from hospitals of their rotations, for clearance in completion of medical records, pager
units, keys, libraries, parking permits/cards, ID badges and scrub suits. Return the form to the
Transitional Year Residency Coordinator.

Residents are referred to the "Graduate Medical Education Trainee Handbook" which was
received with the residency contract for further details about these and other policy issues.




                                                 12
AFFILIATED HOSPITALS



LYNDON B. JOHNSON GENERAL HOSPITAL     LBJ
    5656 Kelley Street
    Houston, TX 77026
    713-566-4646




MEMORIAL HERMANN HOSPITAL              MHH
    6411 Fannin
    Houston, TX 77030-1597
    713-704-4000


THE UNIVERSITY OF TEXAS M.D. ANDERSON CANCER CENTER   MDA
     1515 Holcombe
     Houston, TX 77030-4093
     713-792-2121




                               13
LYNDON B. JOHNSON GENERAL HOSPITAL COURTESIES                            (LBJ)

OFFICE OF THE CHIEF OF STAFF
Room COS 101 is open from 7:30 AM to 5:00 PM, Monday through Friday.

PROVIDER NUMBER
The Harris County Hospital District issues each physician a unique Provider (I.D.) Number to be
used in patient care. The computerized hospital systems such as physician orders, pharmacy and
medical record dictation require this number. This number is issued during the sign-in process
by Physician Services Administration office located at the Lyndon B. Johnson General Hospital
in room 1 PE 18 005, phone 713-566-4656.

PAGERS
Alpha-numeric pagers are provided for each resident by the Memorial Hermann Hospital. Lost
pagers will be replaced at the resident’s cost.

The LBJ Page Operator can be reached at 713-566-5565, or 713-566-5566.

PAGER BATTERIES
During weekdays, batteries can be obtained from the Transitional Year Program Office.

UT/LBJ ACCESS KEY CARD
This card, which serves as an ID badge as well as an access key card to the parking lot and to the
hospital building, is provided free of charge by Harris County Hospital District Security Office.
This office is located at the Kelley Street entrance to the hospital, room 1 PV 10 001, phone 713-
566-5303. The replacement fee for a lost badge is $15.

LOCKERS
Lockers are available in the UT Annex. Anyone wishing to use a locker should contact the
Transitional Year Program Office; the resident must provide his/her own lock. Additionally,
each call room contains closets which can accommodate the resident’s own lock. Residents are
strongly advised to keep personal belongings secured.

PARKING
Residents will have parking privileges in Lot C, the reserved parking lot located on the west side
of the building. A parking decal will be issued by Security at orientation. The decal must be
displayed on the left side of the car’s front windshield.




                                                14
UNIFORMS
Four (4) lab coats are provided to each resident. Laundry service is available through the
Program Office.

SCRUB SUITS
A Scrub Suit Issue form and a LBJGH ID badge are required to receive scrubs. The resident will
complete the format sign-in. Scrubs are obtained through a vending machine system, which will
allow you to access a maximum of 3 sets of scrubs. You may exchange soiled scrubs for equal
amounts of clean scrubs. The machines are located on the 1st floor Employee Entrance, 2nd Floor
Linen Room and on the 3rd floor OR.

CALL ROOM KEYS
A call room is provided for the resident taking in-house call. Residents receive their call room
assignments from the service to which they are assigned for the rotation. When assigned to a
rotation on Internal Medicine or Surgery at the LBJ General Hospital, you may obtain a call room
key from the Physician Services Administration Office, 1PE 18 005. You will be required to
leave a deposit at the time you acquire the key. This deposit is refundable when the key is
returned. During all other rotations, you will obtain a key from either the house staff office or
departmental residency office. The LBJ call room key must be returned at the completion of
your rotation.

ON-CALL MEALS
Two meal tickets will be provided to physicians on call in-house for 24 hours, a $4 ticket for
breakfast, a $6 ticket for dinner. Tickets are non-refundable and non-transferable. A LBJ ID
badge is required to obtain these meals.

CAFETERIA HOURS
The cafeteria serves breakfast from 6:30 AM - 10:00 AM; Lunch from 11:00 AM - 1:30 PM;
salad bar from 1:30 PM-3:00 PM; and dinner from 4:30 PM - 12:00 AM (Deli 4:30 PM-8:00
PM, Hot Line 4:00 PM -8:00 pm, Pizza 2:00-8:00 PM and Grill 2:00 PM -Midnight).

LIBRARIES
The LBJ General Hospital has a main medical library located on the fourth floor, room 4 HL 80
001a-c, near the District Education Office. It is available 24 hours/7 days via key-card entry.
Additionally, each fundamental discipline has a service-specific library available to trainees. The
locations are as follows: Medicine, room 4PO 30 012f; OB/GYN 2BC 63 004; Pediatrics, room
2NT 90 001; Surgery, room 3IC 61 004; Radiology, room 1RD 71 001d. The Jesse H. Jones
Medical Library (HAM-TMC), the main medical library for the Texas Medical Center, located at
1133 MD Anderson Blvd, adjacent to the UT Medical School Building, is open seven days a
week: Monday-Thursday 7 AM - Midnight; Friday 7 AM – 9 PM; Saturday 9 AM – 5 PM;
Sunday 1 PM – 10 PM, and has virtually all journal and text material you will need.

The Kirkendall Library is in the Department of Medicine at the Medical School, room 1.150
MSB and access is available 24/7. Access on nights and weekends is via key pad.


                                                15
LOUNGES
Resident lounges at LBJGH are available in Internal Medicine, Room 3C 51 015, Pediatrics,
Room 2NT 90 001, and OB-GYN, Room 2BC 61 004.

INTERNET ACCESS
Computers with Internet access and access to the Houston Academy of Medicine-Texas Medical
Center Library are available to trainees 24/7. They are located in the 4th floor library, on unit 3B,
in the Medical Intensive Care Unit, at the front desk of the Adult Emergency Center, and the East
Wing Annex room 158. Both the 4th floor library and East Wing room 158 require key-card
access.

SECURITY
Appropriate security measures are taken to protect residents within the hospital and on the
hospital grounds. Hospital District security officers and Harris County sheriff's deputies are on
duty around the clock, including bicycle patrols through parking lots. When leaving the hospital
at night, you may request a security escort to your car. The Security office can be reached at 713-
566-5303.

Security of personal belongings is the resident’s responsibility. Residents are encouraged to
make use of call room closets and available lockers to secure personal belongings. Electronic
devices (PDAs, cell phones, lap top computers), as well as wallets and purses, are particularly
vulnerable.




                                                 16
MEMORIAL HERMANN HOSPITAL COURTESIES (MHH)

HOUSE STAFF AFFAIRS OFFICE
1st Floor-Cullen, 713-704-2683

PHARMACY/I.D. NUMBER
Pharmacy administration assigns house staff physicians, who do not have their own DEA
number, a Hermann DEA number that includes a unique suffix number. This DEA number is
valid only if prescriptions are written in Hermann Hospital clinics or at discharge

PAGERS AND PAGING
To access the Hermann (MHH) Page system (5-digit pager numbers) dial 713-605-8989, then
follow the voice automated instructions. The MHH Page Operator can be reached at 713-704-
4284.

PAGER BATTERIES
Batteries for MHH-issued pagers can be obtained from Telecommunications, located on the first
floor of Robertson Pavilion near the Emergency Center.

LOCKERS
When on call, residents have access to lockers located within call rooms.

PARKING
Parking for house staff will be in the Prairie View A & M Parking Lot. Parking cards are
distributed through the Transitional Year Residency Office.. The actual parking fee will
be paid for by the Transitional Residency Office.

SCRUB SUITS
Inventories are kept in the Auto valet vending machines on second floor Robertson (near O.R.).
You will be issued an Auto valet barcode through the House Staff Affairs Office, which will
allow you to access a maximum of 3 sets of scrubs. You may exchange soiled scrubs for equal
amounts of clean at the Auto valet, open 24 hours, 7 days/week. Any suits lost or misplaced will
cost $10 to replace.

CALL ROOMS
Call room assignment and key distribution are coordinated through the House Staff Affairs
Office. The key deposit is incorporated into the $10 parking deposit.

MEAL TICKETS
Are a benefit extended by the hospital for the house staff while on call. Tickets are distributed
through House Staff Affairs Office to departmental residency offices. Meal Tickets are NOT
transferable and are contingent upon prompt completion of Medical Records. The cashier will
accept only one ticket per meal.



                                                17
CAFETERIA HOURS
The cafeteria is open from 6:00 AM - 2:00 AM.


LIBRARIES
The main resource for medical research is the Jesse Jones Library in the Texas Medical Center,
adjacent to the hospital campus (www.library.tmc.edu/). Hours of operation are: Monday-
Thursday 7 AM - Midnight; Friday 7 AM – 9 PM; Saturday 9 AM – 5 PM; Sunday 1 PM – 10
PM.

The Kirkendall Library located in the Department of Medicine in the Medical School building
room 1.150 is available 24/7. Access on nights and weekends is via key pad.

The Library for the Department of Pediatrics in room 10.147 in the Hermann Pavilion of the
Memorial Hermann Hospital is available 24/7. Access on nights and weekends is via key pad.

LOUNGE
The resident lounge is located on the 4th floor of Robertson Pavilion.

SECURITY
Appropriate security measures are taken to protect residents within the hospital and on the
hospital grounds. Hermann Hospital security officers and Houston Police Department officers
are on duty around the clock. When leaving the hospital at night, you may request a security
escort to your car. The Security office can be reached at 713-704-0000.

Security of personal belongings is the resident’s responsibility. Residents are encouraged to
make use of call room lockers to secure personal belongings. Electronic devices (PDAs, cell
phones, lap top computers), as well as wallets and purses are particularly vulnerable.




                                                18
THE UNIVERSITY OF TEXAS M.D. ANDERSON CANCER CENTER COURTESIES

ORIENTATION
Handled by Sylvia Laws, phone number: 713/745-157
8:00 AM, room B2.4759 with Jose A. Cortes, M.D.

I.D. BADGE AND PHYSICIAN ID NUMBER
Monday through Thursday, 8:00 AM – 4:30 PM; Friday 8:00 AM – Noon
Location: Pickens Tower, 1400 Pressler Street, 7th floor, Room FCT 7.5000.
Contact Denise LaGrone at 713/745-0939 or Sarah Broussard at 713/794-5814

RESEARCH MEDICAL LIBRARY
At the UT MD Anderson Cancer Center, the Research Medical Library is located in Pickens
Tower, 21st floor, Room FCT 21.5000. Hours of operation are: Monday-Thursday from 7:30
AM to 9:00 PM; Friday from 7:30 AM to 7:00 PM; Saturday from 10:00 AM to 5:00 PM; and
closed Sunday . In addition to an extensive collection of print and electronic publications, access
to databases and literature searches, the library contains computers with internet access in public
areas of the library.

FOOD SERVICES
Food facilities at the UT MD Anderson Cancer Center include: a full-service main cafeteria
open daily 6:30 AM to 8:30 PM; Café 24/7 open 24 hours/7 days is a coffee shop offering
Starbucks, Smoothie King, prepared sandwiches and salads; four coffee bars open Monday-
Friday from 8:30 AM to 4:30 PM; and a main vending lounge open 24 hours/7 days.

PARKING
Parking for house staff will be in the Prairie View A & M Parking Lot. Parking cards are
distributed through the Transitional Year Residency Office.. The actual parking fee will
be paid for by the Transitional Residency Office.




                                                19
TRANSITIONAL YEAR PROGRAM SPONSORING DEPARTMENTS

       MEDICINE
           Mark Farnie, MD, Program Director
           UT-Medical School MSB 1.126
           713-500-6507

               Phyllis Martin, Residency Coordinator,
               713-500-6525

               PEDIATRICS
               Keely Smith, MD, Program Director
               UT-Medical School MSB 3.244
               713-500-5802

               Shirlene Edwards, Residency Coordinator
               713-500-5800

               SURGERY
               John Potts, MD, Program Director
               UT-Medical School MSB 4.274
               713-500-7237

               Kathalyn Gonzalez, Residency Coordinator
               713-500-7216



ROTATIONS
Residents will be trained at the Lyndon B. Johnson General Hospital, Memorial Hermann
Hospital, and at the University of Texas MD Anderson Cancer Center. Of these three
institutions, Lyndon B. Johnson General Hospital serves as the parent institution for the
Transitional Year Program and the site for most of the rotations. While responsibilities vary with
each rotation, the Transitional Year resident will serve as an intern on inpatient services,
outpatient clinics, emergency center and critical care units.




                                               20
GOALS AND OBJECTIVES OF THE TRANSITIONAL YEAR PROGRAM

Before completion of the Transitional Year, the resident will develop the following fundamental
clinical competencies:
            obtain a complete medical history
            perform a complete physical examination
            define a patient's problems
            develop a rational plan for diagnosis
            implement therapy based upon the etiology, pathogenesis and clinical
               manifestations of various diseases
            develop humane qualities that enhance interactions between the physician, the
               patients, and the patients’ families.
            develop mature clinical judgment through patient care, well-documented record
               keeping, order writing and continuing management commensurate with his/her
               ability.

Additionally, Transitional Year residents will be able to demonstrate the general competencies as
defined by the Accreditation Council for Graduate Medical Education, namely:
            patient care
            medical knowledge
            practice-based learning and improvement
            interpersonal and communications skills
            professionalism
            systems-based practice

The successful completion of the Transitional Year will depend on the resident’s ability to
demonstrate these competencies, as determined by the attending physicians and the Program
Director.




                                               21
GOALS AND OBJECTIVES OF THE CLINICAL ROTATIONS




                      22
                             LBJ GENERAL MEDICAL SERVICES A – D

Transitional Year residents assigned to the LBJ Hospital general ward services work in four teams
consisting of two senior residents (combination of PGY2, PGY3 or PGY-4 if Med-Peds) and four interns.
One senior resident will work with two interns. On-Call frequency is every fourth night and starts at 7AM
and ends at 6:45 AM. However, admissions are accepted only until 2:00 AM.

All ward teams care for patients with both general medical and subspecialty problems across the full age
range from adolescence to the elderly. Resident teams develop diagnostic and therapeutic management
plans in collaboration with the attending physician of record through daily evaluation and discussion. The
rotation is for one month, with one day off every week. Adherence to the 80 hour work week is
mandatory.



  Legend for Learning Activities
  AR – Attending Rounds          DrFR – Dr. Fred Rounds                     MP – Med-Path Conference
                                 EBM-Evidence Based Medicine                MedRad –Med-Rad Conf.
  CPC–Clinicopathologic          FS – Faculty Supervision                   MR – Morning Report
   Conf.                         GR – Grand Rounds                          NC – Noon Conferences
  CC-Core Curriculum             IL-Introductory Lecture Series             PathCl-Pathology Clinicians
  DPC – Direct Patient Care      MJ – Medical Jeopardy                      SS – Senior Seminar
  DSP – Directly Supervised      LL-Lunch and Learn series                  EMC-Emergency Medicine
    Procedures                   DO H&P –Direct observation of              Conference
  JC-Journal Club                an H&P (adult and pediatrics-              PC-Professional Curriculum
                                 twice yearly)

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                  PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures        PR – Peer Review
  MR – Morning Report                         TYPD-TY Program Director


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.


A. Patient Care

                                                                                   Learning        Evaluation
        Principal Educational Goals
                                                                                   Activities      Methods
 1.      Ability to take a complete medical history and perform a careful          DPC, AR,        AE, MR
        and accurate physical examination                                          MR, PC
 2.      Ability to write concise, accurate and informative histories, physical                    AE
                                                                                   DPC, AR
        examinations and progress notes.
 3.      Define and prioritize patients’ medical problems and generate             DPC, AR,        AE, MR
        appropriate differential diagnoses.                                        MR

                                                       23
 4.                                                                               DPC, AR,     AE, MR
       Develop rational, evidence-based management strategies.
                                                                                  MR, PC
 5.                                                                               DPC, CC,
        Ability to make basic interpretation of chest and abdominal x-rays
                                                                                  IL           AE
       and electrocardiograms.
 6.                                                                               DPC, DSP,    AE,
                                                                                  AR,          DSP,TYPD
        Ability to perform basic procedures: venipuncture, arterial
                                                                                  LL
       puncture, placement of central venous lines, lumbar puncture,
       abdominal paracentesis, thoracentesis, arthrocentesis, and
       nasogastric intubation.


 7.    Participation and later leadership of discussions of end-of-life issues    DPC, AR,     AE, TYPD
       with families.                                                             LL

B. Medical Knowledge

                                                                                  Learning     Evaluation
        Principal Educational Goals
                                                                                  Activities   Methods
  1.                                                                              DPC, AR,     AE, MR
        Expand clinically applicable knowledge base of the basic and
                                                                                  MR, NC,
        clinical sciences underlying the care of medical patients
                                                                                  GR
  2.    Access and critically evaluate current medical information and            DPC, AR,     AE
        scientific evidence relevant to patient care                              MR, GR
  3.                                                                              DPC, AR,     AE, MR
        Understand basic pathophysiology, clinical manifestations,
                                                                                  MR, NC,
        diagnosis and management of medical illnesses seen on a general
                                                                                  GR
        medicine inpatient service.
  4.                                                                              DPC, AR,     AE
        Recognize the indications for and basic interpretation of chest and
                                                                                  MR
        abdominal X-rays, electrocardiograms, and pulmonary function
        tests.
  5.                                                                              DPC, AR,     AE
        Learn indications for and basic interpretation of standard laboratory     MR, GR
        tests, including blood counts, coagulation studies, blood chemistry
        tests, urinalysis, body fluid analyses, and microbiologic tests.

  6                                                                                            AE


        Familiarity with special features of diagnosis, interpretation of tests   DPC, AR,
        and management of illnesses in a geriatric population.                    MR, GR




C. Interpersonal Skills and Communication



                                                     24
                                                                                Learning      Evaluation
       PRINCIPAL EDUCATIONAL GOALS
                                                                                Activities    Methods
  1.                                                                            DPC, AR,      AE, TYPD
       Communicate effectively with patients and families.
                                                                                PC, LL
  2.
       Communicate effectively with all physician colleagues and other    DPC, AR,            AE
       members of the health care team to assure comprehensive and timely MR
       care of hospitalized patients.

  3.   Present information concisely and clearly both verbally and in           DPC, AR,      AE
       writing on patients.                                                     MR

D. Professionalism

                                                                                Learning      Evaluation
        Principal Educational Goals
                                                                                 Activities   Methods
  1.   Interact professionally towards patients, families, colleagues, and all DPC,AR,MR
       members of the health care team.                                            ,PC, LL    AE,TYPD
  2.   Acceptance of professional responsibility as the primary care           DPC, AR,       AE
       physician for patients under his/her care.                                  MR, PC
  3.                                                                           DPC, AR,       AE, TYPD
       Appreciation of the social context of illness.                              MR, LL,
                                                                                   PC
  4.   Knowing when and how to request ethics consultation, and how best DPC, AR,             AE, TYPD
       to utilize the advice provided.                                             PC,LL
  5.   Understand ethical concepts of confidentiality, consent, autonomy       DPC, AR,       AE, TYPD
       and justice.                                                                PC, LL
  6.   Understand professionalism concepts of integrity, altruism and                         AE
                                                                               DPC, PC
       conflict of interest.
  7.   Increase self-awareness to identify methods to manage personal and
                                                                               PC, NC, GR
       professional sources of stress and burnout.                                            PDR
  8.   Increase knowledge and awareness of personal risks concerning
       drug/alcohol abuse for self and colleagues, including referral,         PC, NC, GR     PDR
       treatment and follow-up.

E.Practice-Based Learning and Improvement

                                                                                Learning       Evaluation
        Principal Educational Goals
                                                                                Activities    Methods
 1.     Identify and acknowledge gaps in personal knowledge and skills in       DPC,          AE
        the care of hospitalized patients.                                      AR,MR
 2.     Develop and implement strategies for filling gaps in knowledge and                    AE
                                                                                AR, CC
        skills.
 3.     Commitment to professional scholarship, including systematic and        DPC, AR,      AE
        critical perusal of relevant print and electronic literature, with      GR, MR,
        emphases on integration of basic science with clinical medicine,        NC
        and evaluation of information in light of the principles of evidence-
        based medicine.


                                                   25
F. Systems-Based Practice

                                                                               Learning      Evaluation
       Principal Educational Goals
                                                                               Activities   Methods
 1.    Understand and utilize the multidisciplinary resources necessary to                  AE
                                                                               DPC
       care optimally for hospitalized patients
 2.    Collaborate with other members of the health care team to assure                     AE
                                                                               DPC
       comprehensive patient care
 3.    Use evidence-based, cost-conscious strategies in the care of            DPC, AR,     AE
       hospitalized patients                                                   MR
 4.    Understand when to ask for help and advice from senior residents                     AE
                                                                               DPC, AR,
       and attending physicians
 5.    Effective collaboration with other members of the health care team,     DPC, AR      AE
       including residents at all levels, medical students, nurses, clinical
       pharmacists, occupational therapists, physical therapists, nutrition
       specialists, patient educators, speech pathologists, respiratory
       therapists, enterostomy nurses, social workers, case managers,
       discharge planners, clinical pharmacists and providers of home
       health services
 6.
       Knowing when and how to request medical subspecialist, and how
                                                                               DPC, AR      AE
       best to utilize the advice provided.
 7.    Consideration of the cost-effectiveness of diagnostic and treatment     DPC, AR,     AE
       strategies.                                                             MR




                                                   26
              MEMORIAL HERMANN GENERAL WARD SERVICES A – D

     Transitional Year residents assigned to the Memorial Hermann Hospital General Ward
Services rotation work in four teams of one senior resident (either PGY2 or PGY3) and two
interns (PGY1) during the month long rotation. All ward teams care for patients with both
general medical and subspecialty problems across the full age range from adolescence to the
elderly. Resident teams develop diagnostic and therapeutic management plans in collaboration
with the attending physician of record through daily evaluation and discussion. Call is every
fourth night, the team on call takes up to10 admissions. The post-call team leaves the hospital at
1:00 PM, at which point the post-call cover resident assumes all aspects of patient care. There is
one day off during the week.

   Patients seen on the Memorial Hermann General Medicine Services A - D rotation are in
Memorial Hermann Hospital on the general medicine services. They include patients without a
previously documented faculty physician from clinics or the ER, patients referred to faculty
physicians, private patients of faculty physicians, patients of community practitioners (mostly
former UTHMS residents), and managed care patients. Patients can be transferred to the Skilled
Nursing Facility and are still followed by the team, requiring notes twice weekly.



  Legend for Learning Activities
  AR – Attending Rounds       DSP – Directly Supervised               M&M-Morbidity & Mortality
                              Procedures                              MP – Med/Path Conference
  Au – Autopsy Report         EBM - Evidence Based Med                MR – Morning Report
  CR – Chairman’s Rounds      FS – Faculty Supervision                NC – Noon Conferences
  CPC–Clinicopathologic       GR – Grand Rounds                       PathCl- Path for Clinicians
   Conf.                                                              PC–Professionalism Curriculum
  CC-Core Curriculum          IL-Introductory Lecture Series          SS – Senior Seminar
  DPC – Direct Patient Care   JC – Journal Club                       LL - Lunch & Learn Series
                              MJ – Medical Jeopardy

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations            PDR–Program Director’s Review (twice annually)
  DSP – Directly Supervised Procedures  PR – Peer Review
  IE – In-service Exam                  TYPD – Transitional Year Program Director
  MR – Morning Report

Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.




                                                   27
   A. Patient Care


                                                                 Learning       Evaluation
      Principal Educational Goals
                                                                 Activities     Methods
 2.    Ability to take a complete medical history and                           AE, MR
                                                                 DPC, AR, MR
      perform a careful and accurate physical examination.
 2.    Ability to write concise, accurate and informative                       AE
                                                                 DPC, AR
      histories, physical examinations and progress notes.
 3.    Define and prioritize patients’ medical problems and      DPC, AR, CR,   AE, MR
      generate appropriate differential diagnoses.               MR
 4.    Develop rational, evidence-based management               DPC, AR, MR,   AE, MR
      strategies.                                                JC, EBM
 5.   Ability to perform basic procedures: venipuncture,         DPC, AR, DSP   AE, DSP
      arterial puncture, placement of central venous lines,
      lumbar puncture, abdominal paracentesis,
      thoracentesis, arthrocentesis, nasogastric intubation,
      and endotrachael intubation.

 6.   Participation and later leadership of discussions of       DPC, AR, PC, LL AE, TYPD
      end-of-life issues with families.



B. Medical Knowledge

                                                                 Learning       Evaluation
       Principal Educational Goals
                                                                 Activities     Methods
 1.    Expand clinically applicable knowledge base of the                       AE, MR
                                                                 AR, CR, DPC,
       basic and clinical sciences underlying the care of
                                                                 EBM, NC, MR
       medical patients.
 2.    Access and critically evaluate current medical                           AE
                                                                 AR, CR, DPC,
       information and scientific evidence relevant to patient
                                                                 EBM, NC, MR
       care.
 3.    PG-1 Understand basic pathophysiology, clinical                          AE
       manifestations, diagnosis and management of               AR, CR, DPC,
       medical illnesses seen on a general medicine inpatient    EBM, NC, MR
       service.


 4.    PG-1- Recognize the indications for and basic                            AE
                                                                 AR, CR, DPC,
       interpretation of chest and abdominal X-rays,
                                                                 EBM, NC, MR
       electrocardiograms, and pulmonary function tests.



                                               28
 5.     PG-1 - Learn indications for and basic interpretation                       AE,
        of standard laboratory tests, including blood counts,
                                                                  AR, CR, DPC,
        coagulation students, blood chemistry tests,
                                                                  EBM, NC, MR
        urinalysis, body fluid analyses, and microbiologic
        tests.

C. Interpersonal Skills and Communication

                                                                Learning        Evaluation
       PRINCIPAL EDUCATIONAL GOALS
                                                                Activities      Methods
  1.   Communicate effectively with patients and families.      DPC, AR, PC, FS AE, MR
  2.   Communicate effectively with physician colleagues        DPC, AR, MR,      AE, MR, PR
       at all levels.                                           PC, CR, FS
  3.   Communicate effectively with all non-physician
                                                                DPC, AR, PC, FS
       members of the health care team to assure                                  AE, MR
       comprehensive and timely care of hospitalized
       patients.
  4.   Present information concisely and clearly both                             AE, MR
                                                                AR, MR, CR, NC
       verbally and in writing on patients.

D. Professionalism

                                                                Learning           Evaluation
       Principal Educational Goals
                                                                 Activities        Methods
 1.    Interact professionally towards patients, families,                        AE, PR
                                                              DPC, AR, PC, MR
       colleagues, and all members of the health care team.
 2.    Acceptance of professional responsibility as the                       AE , PR
                                                              DPC, AR, PC
       primary care physician for patients under his/her care
 3.    Appreciation of the social context of illness.         DPC, AR, PC     AE
 4.    Knowing when and how to request ethics                                     AE, TYPD
       consultation, and how best to utilize the advice         DPC, AR, PC, LL
       provided.
 5.    Understand ethical concepts of confidentiality,                            AE, TYPD
                                                                DPC, AR, PC, LL
       consent, autonomy and justice.
 6.    Understand professionalism concepts of integrity,                          AE, TYPD
                                                                DPC, AR, PC, LL
       altruism and conflict of interest.
 7.    Increase self-awareness to identify methods to                             TYPD, PDR
       manage personal and professional sources of stress       DPC, PC, LL
       and burnout.
 8.    Increase knowledge and awareness of personal risks                         AE
       concerning drug/alcohol abuse for self and
                                                                DPC, PC
       colleagues, including referral, treatment and follow-
       up.

                                               29
E. Practice-Based Learning and Improvement

                                                                   Learning        Evaluation
       Principal Educational Goals
                                                                   Activities     Methods
 1.    Identify and acknowledge gaps in personal                   DPC, AR, CR,   AE, MR
       knowledge/skills in the care of hospitalized patients.      NC
 2.    Develop and implement strategies for filling gaps in                    AE, PDR
                                                               DPC, AR, JC, NC
       knowledge and skills.
 3.    Commitment to professional scholarship, including                       AE
                                                               DPC, AR, EBM,
       systematic, critical perusal of relevant print and
                                                               JC, CR
       electronic literature, with emphases on integration of
       basic science with clinical medicine, and evaluation
       of information in light of principles of evidence-based
       medicine.

F. Systems-Based Practice

                                                                   Learning        Evaluation
       Principal Educational Goals
                                                                   Activities     Methods
 1.    Understand and utilize the multidisciplinary resources                     AE, MR
                                                                   DPC, MR
       necessary to care optimally for hospitalized patients.
 2.    Use evidence-based, cost-conscious strategies in the        DPC, AR, CR,   AE, MR
       care of hospitalized patients.                              MR, NC, EBM
 3.    Understanding when to ask for help and advice from                         AE
                                                                   DPC, AR, CR
       senior residents and attending physicians.
 4.    Effective collaboration with other members of the           DPC, AR, PC    AE
       health care team, including residents at all levels,
       medical students, nurses, clinical pharmacists,
       occupational therapists, physical therapists, nutrition
       specialists, patient educators, pathologists, respiratory
       therapists, enterostomy nurses, social workers, case
       managers, discharge planners, clinical pharmacists
       and providers of home health services.
 5.    Consideration of the cost-effectiveness of diagnostic       DPC, AR, CR,   AE
       and treatment strategies.                                   NC, PC




                                                30
     LBJ AMBULATORY/MEMORIAL HERMANN AMBULATORY BLOCK ROTATION

The Transitional Year intern participates in the LBJ or Memorial Hermann ambulatory rotation for one month.
At LBJ, the resident primarily rotates through several subspecialty units, usually one per day, in addition to
seeing some general medicine clinic patients. The resident works with an attending, most of who are
subspecialty faculty members. The hours are from 8:00am to 11:50am, and 1:00pm to 5:00 pm. The LBJ
patients are typically non-resource patients, or patients who lack funds for private physician’s care. At
Memorial Hermann Hospital the ambulatory rotation is also for one month. There, the residents see general
medicine outpatients in the general Internal Medicine clinics each weekday from approximately 9:00am to
4:00pm. Faculty members supervise the residents in the clinics and provide ongoing teaching during the
rotation.

  Legend for Learning Activities
  AR – Attending Rounds DSP – Directly Supervised                           M&M-Morbidity & Mortality
                                 Procedures                                 MP – Med/Path Conference
  Au – Autopsy Report            EBM - Evidence Based Med                   MR – Morning Report
  CR – Chairman’s Rounds         FS – Faculty Supervision                   NC – Noon Conferences
  CPC–Clinicopathologic          GR – Grand Rounds                          PathCl- Path for Clinicians
   Conf.                         IL-Introductory Lecture Series             PC–Professionalism Curriculum
  CC-Core Curriculum             JC – Journal Club                          SS – Senior Seminar
  DPC – Direct Patient Care      MJ – Medical Jeopardy                      L&L-Lunch and Learn


  Legend for Evaluation Methods for Residents
  FE - Faculty Evaluations                                     PR – Peer Review
  DSP – Directly Supervised Procedures
  PDR–Program Director’s Review (quarterly)


Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.




                                                       31
      A. Patient Care

                                                                      Learning        Evaluation
        Principal Educational Goals
                                                                      Activities      Methods
1.      Ability to take a good medical history and perform a careful DPC              FE
        and accurate physical examination.
2.      Ability to write concise, accurate and informative histories, DPC             FE
        physical examinations and progress notes.
3.                                                                    DPC             FE
        Maintain focus and timeliness in the evaluation and
        management of ambulatory problems.

4.      Understand and implement appropriate strategies for disease DPC               FE
        prevention and health promotion.
5.      Develop strategies to efficiently evaluate and manage DPC                     FE
        common ambulatory medical problems.
6.                                                                  DPC               FE
        Ability to formulate comprehensive and accurate problem
        lists, differential diagnoses and plans of management.
7.                                                                                    FE
                                                                        DPC, CC
        Ability to make basic interpretation of chest and abdominal
        x-rays.

8.                                                                      DPC, CC, IL   FE
         Ability to make basic interpretation of electrocardiograms.


9.                                                                      DPC           FE
         Ability to perform pelvic examination under supervision.
10.     Willingness and ability to help patients engage in strategies                 FE
                                                                      DPC
        of disease prevention.


B. Medical Knowledge

                                                                        Learning      Evaluation
         Principal Educational Goals
                                                                        Activities*   Methods
 1.      Expand clinically applicable knowledge base of the basic
         and clinical sciences underlying the care of ambulatory        DPC, IL, CC   FE
         patients.
 2.      Access and critically evaluate current medical information
                                                                        DPC, SS
         and scientific evidence relevant to ambulatory patient care.                 FE
 3.       Understanding the basic pathophysiology, clinical
                                                                        DPC, CC
         manifestations, diagnosis and management of medical                          FE
         illnesses commonly seen by a general internist in the
         ambulatory setting.
 4.      Understanding the clinical manifestations, diagnosis and
                                                                        DPC, IL
         management of problems commonly seen in adolescents.                         FE


                                                     32
 5.    Familiarity with indications for and interpretation of chest
       and abdominal X-ray, electrocardiograms, and pulmonary DPC, CC               FE
       function tests.
 6.
       Familiarity with indications for and interpretation of
                                                                                    FE
       standard laboratory tests, including blood counts, DPC, CC
       coagulation studies, blood chemistry tests, urinalysis, body
       fluid analyses, and microbiologic tests.
 7.                                                                  DPC, CC        FE
       Familiarity with basic principles of disease prevention,
       including adult immunizations, cardiovascular risk
       assessment, prevention of cardiovascular disease, screening
       for cancer, prevention of osteoporosis and cessation of use
       of tobacco.
 8.    Basic familiarity with pathophysiology, clinical
       manifestations and non-operative management of common                        FE
                                                                     DPC, GR
       musculoskeletal conditions, including occupational and
       sports-related injuries.
 9.    Basic familiarity with pathophysiology, clinical
                                                                     DPC, GR, L&L
       manifestations and medical management of common                              FE
       gynecological conditions, including acute salpingitis,
       vaginitis, dysmenorrhea, irregular menses and menopausal
       symptoms.
 10.    Basic familiarity with pathophysiology, clinical
       manifestations and medical management of common               DPC GR         FE
       otolaryngological conditions, including acute and chronic
       sinusitis and allergic rhinitis.
 11.   Basic familiarity with pathophysiology, clinical
       manifestations and management of common ophthalmologic        DPC, LL        FE
       conditions, including minor ocular injuries and
       conjunctivitis.

C. Interpersonal Skills and Communication

                                                                     Learning       Evaluation
       Principal Educational Goals
                                                                     Activities*    Methods
 1.    Communicate effectively with patients and families across a
                                                                   DPC, PC, LL
       broad range of socioeconomic and ethnic backgrounds.                         FE
 2.    Communicate effectively with physician colleagues and
       members of other health care professions to assure DPC, PC                   FE
       comprehensive patient care.

D. Professionalism

                                                                     Learning       Evaluation
       Principal Educational Goals
                                                                     Activities*    Methods
 1.    Interact professionally towards patients, families,
                                                            DPC, PC, LL
       colleagues, and all members of the health care team.                         FE


                                                   33
  2.     Appreciation of the social context of illness.                  DPC, PC, LL   FE


E. Practice-Based Learning and Improvement

                                                                         Learning      Evaluation
         Principal Educational Goals
                                                                         Activities    Methods
 1.      Identify and acknowledge gaps in personal knowledge and
                                                                      DPC
         skills in the care of ambulatory patients.                                    FE
 2.      Develop real-time strategies for filling knowledge gaps that
                                                                      DPC
         will benefit patients in a busy practice setting.                             FE
 3.      Commitment to professional scholarship, including
         systematic and critical perusal of relevant print and                         FE
                                                                      DPC, CC, SS
         electronic literature, with emphases on integration of basic
         science with clinical medicine, and evaluation of
         information in light of the principles of evidence-based
         medicine.


      F.Systems-Based Practice

                                                                         Learning      Evaluation
         Principal Educational Goals
                                                                         Activities    Methods
1.       Understand and utilize the multidisciplinary resources
                                                                         DPC
         necessary to care optimally for ambulatory patients.                          FE
2.       Collaborate with other members of the health care team to
                                                                         DPC
         assure comprehensive ambulatory patient care.                                 FE
3.       Use evidence-based, cost-conscious strategies in the care of
                                                                         DPC, SS
         ambulatory patients.                                                          FE
4.       Begin to understand the business aspects of practice
                                                                         GR, NC
         management in a variety of settings.                                          FE
5.       Knowing when to consult or refer a patient to a medical
                                                                         DPC
         subspecialist.                                                                FE
6.       Knowing when to refer patients to specialists in orthopedics,
                                                                         DPC
         gynecology, otolaryngology and ophthalmology.                                 FE
7.       Effective utilization of medical consultants, including
         knowing when and how to request consultation, and how best      DPC           FE
         to utilize the advice provided.
8.       Consideration of the cost-effectiveness of diagnostic and                     FE
                                                                         SS, GR
         treatment strategies.




                                                      34
                           LBJ MEDICAL INTENSIVE CARE UNIT

The LBJ Hospital Intensive Care Unit (MICU) is a 16-bed unit shared with CCU and SICU
patients specializing in the care of critically ill patients from a wide spectrum of medical and
neurologic etiologies. Conditions cared for in the MICU include but are not limited to: acute
hypoxia, acute respiratory distress syndrome, acid-base imbalances, liver and renal failure, acute
stroke, intracranial hemorrhage, status epilepticus, and coma. MICU rotations are one month in
length, and the unit is staffed with three residents and three interns. Call on the rotation is every
third night, post-call residents leave the hospital by 1:00pm the next day, and there is one day off
during the week. Residents assigned to the MICU are exempt from Morning Report, but are
required to attend the Noon Conferences.

The residents work closely with the Pulmonary/Critical Care Attending and Fellow during this
rotation, and have the opportunity to learn procedures such as placement of central venous and
arterial lines under the direct supervision of the attending or fellow. They may participate in
placement of Swan-Ganz catheters.

Patients seen on the LBJ Medical Intensive Care Unit rotation include patients admitted to the
MICU, patients transferred from an internal medicine service, patients admitted directly to the
MICU from ER, and patients transferred to LBJ MICU from outside hospitals.

  Legend for Learning Activities
  AR – Attending Rounds       DrFR – Dr. Fred Rounds                  MP – Med-Path Conference
                              EBM-Evidence Based                      MedRad –Med-Rad Conf.
  CPC–Clinicopathologic       Medicine                                MR – Morning Report
   Conf.                      FS – Faculty Supervision                NC – Noon Conferences
  CC-Core Curriculum          GR – Grand Rounds                       PathCl-Pathology Clinicians
  DPC – Direct Patient Care                                           PC–Professionalism Curriculum
  DSP – Directly Supervised   IL-Introductory Lecture Series          SS – Senior Seminar
   Procedures                 MJ – Medical Jeopardy                   LL -Lunch & Learn Series

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations              PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures    PR – Peer Review
  MR – Morning Report                     TYPD – Transitional Year Program Director


Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.



                                                   35
A. Patient Care

                                                                Learning        Evaluation
       Principal Educational Goals
                                                                Activities      Methods
  1.   Ability to take a complete medical history and                           AE
                                                                DPC, AR
       perform a careful and accurate physical examination.
  2.   Ability to write concise, accurate and informative                       AE
                                                                DPC, AR
       histories, physical examinations and progress notes.
  3.   Effectively evaluate and manage patients with critical                   AE
                                                                DPC, CC, GR,
       medical illness, including those on mechanical
                                                                NC
       ventilation and vasopressors.
  4.   Effectively evaluate and manage patients with critical                   AE
                                                                DPC, AR
       neurological illness.
  5.   Ability to formulate comprehensive and accurate
                                                                DPC, AR, CC,
       problem lists, differential diagnoses and plans of                       AE
                                                                GR
       management for a critically ill patient.
  6.   Insert central venous lines and arterial lines with                      AE, DSP
                                                                DPC, DSP, FS
       proper technique.
  7.                                                            DPC, AR, DSP,
       Ability to perform basic procedures: venipuncture,
                                                                FS              AE, DSP
       arterial puncture, placement of central venous lines,
       lumbar puncture, abdominal paracentesis,
       thoracentesis, arthrocentesis, and nasogastric
       intubation.
  8.                                                                            AE, DSP
                                                                DPC, DSP, FS
       Ability to perform endotracheal intubation under
       close supervision.

  9.                                                            DPC, DSP, AR,   AE, DSP
       Ability to perform basic ventilator management.
                                                                FS

  10. Insertion and basic management of pulmonary arterial DPC, DSP, AR,        AE, DSP
      catheters under close supervision.                   FS



  11. Ability to make basic interpretation of chest and         DPC, AR         AE
      abdominal x-rays and electrocardiograms.


  12. Ability to perform cardiopulmonary resuscitation and      DPC, DSP, AR,   AE, DSP
      advanced cardiac life support.                            FS




                                              36
  13. Participation in and later leadership of discussion of                     AE
                                                                  DPC, AR, PC
      end-of-life issues with families.

B. Medical Knowledge

                                                                  Learning       Evaluation
       Principal Educational Goals
                                                                  Activities     Methods
  1.   Expand clinically applicable knowledge base of the
                                                                  DPC, AR, CC,
       basic and clinical sciences underlying the care of                        AE
                                                                  NC,GR
       patients with critical medical and neurological illness.
  2.   Access and critically evaluate current medical
       information and scientific evidence relevant to            DPC, SS, NC    AE
       medical and neurological critical care.
  3.   Understand the physiologic and pathophysiologic
       principles of invasive hemodynamic monitoring              DPC, AR        AE
       including indications.
  4.   Understanding the basic pathophysiology, clinical          DPC, AR, CC,   AE
       manifestations, diagnosis and management of severe         NC
       and life-threatening medical illnesses.


  5.   Familiarity with the basic principles of ventilator        DPC, AR, CC,   AE
       management.                                                NC

  6.   Familiarity with the basic principles of                                  AE
                                                                  DPC, AR, CC,
       pathophysiology, diagnosis and management of
                                                                  NC
       respiratory failure.

       .
  7.   Familiarity with the basic principles of            DPC, AR, CC,          AE
       pathophysiology, diagnosis and management of sepsis NC
       and the syndrome of multiple organ failure.

  8.   Familiarity with indications for performance and
                                                                  DPC, AR, CC,
       basic interpretation of blood counts, coagulation                         AE
                                                                  NC
       studies, blood chemistry tests, urinalysis, body fluid
       analyses, microbiologic tests, spirometry and arterial
       blood gases.
  9.   Basic familiarity with indications for and                 DPC, AR, CC,   AE
       interpretation of chest and abdominal X-ray,               NC
       electrocardiograms, and pulmonary function tests.

       .

                                               37
C. Interpersonal Skills and Communication

                                                                  Learning       Evaluation
        Principal Educational Goals
                                                                  Activities     Methods
  1.    Communicate effectively with patients and families in                    AE, TYPD
        a stressful critical care environment, including      DPC, AR, PC, LL
        discussion of end-of-life issues and limits of care.
  2.    Communicate effectively with physician colleagues
        and members of other health care professions to       DPC, AR, PC     AE
        assure timely, comprehensive patient care.
  3.    Communicate effectively with colleagues when                          AE
        signing out DPC, TR patients or turning over care to  DPC
        another service.

D. Professionalism

                                                                  Learning       Evaluation
         Principal Educational Goals
                                                                  Activities      Methods
   1.    Interact professionally toward towards patients,
         families, colleagues, and all members of the health      DPC, AR, PC    AE
         care team.
   2.    Acceptance of professional responsibility as the
         primary care physician for patients under his/her        DPC, AR, PC    AE
         care.
   3.    Appreciation of the social context of illness.           DPC, AR, PC    AE
   4.    Effective utilization of ethics consultants, including
         knowing when and how to request consultation, and        DPC, AR, PC, LL AE, TYPD
         how best to utilize the advice provided.

E. Practice-Based Learning and Improvement

                                                                  Learning       Evaluation
        Principal Educational Goals
                                                                  Activities     Methods
   1.   Identify and acknowledge gaps in personal
        knowledge and skills in the care of patients with         DPC, AR, MR    AE
        critical medical and neurological illness.
   2.   Develop real-time strategies for filling knowledge
        gaps that will benefit patients in the medical            AR, SS, NC     AE
        intensive care unit.
   3.   Commitment to professional scholarship, including         AR, SS, NC     AE
        systematic and critical perusal of relevant print and
        electronic literature, with emphases on integration of

                                                38
     basic science with clinical medicine, and evaluation
     of information in light of the principles of evidence-
     based medicine.


F. Systems-Based Practice

                                                                Learning          Evaluation
     Principal Educational Goals
                                                                Activities        Methods
1.   Understand and utilize the multidisciplinary
     resources necessary to care optimally for critically ill   DPC, AR           AE
     medical and neurological patients.
2.   Collaborate with other members of the health care                            AE
     team to assure comprehensive care for patients with        DPC, AR
     critical medical and neurological illness.
3.   Use evidence-based, cost-conscious strategies in the                         AE
                                                                DPC, AR, SS, NC
     care of patients with critical medical and
     neurological illness.
4.   Knowing when to consult a medical subspecialist.           DPC, AR           AE
5.   Knowing when to ask for help and advice from                                 AE
                                                                DPC, AR
     senior residents and attending physicians.
6.   Learning by participation in ward rounds, teaching                           AE
                                                                DPC
     conferences and other educational activities.
7.   Effective collaboration with other members of the                            AE
                                                                DPC, PC
     health care team, including residents at all levels,
     medical students, nurses, clinical pharmacists,
     occupational therapists, physical therapists, nutrition
     specialists, patient educators, speech pathologists,
     respiratory therapists, enterostomy nurses, social
     workers, case managers, discharge planners, clinical
     pharmacists and providers of home health services.
8.   Effective utilization of medical consultants,
     including knowing when and how to request                  DPC, PC           AE
     consultation, and how best to utilize the advice
     provided.
9.   Consideration of the cost-effectiveness of diagnostic      DPC, AR           AE
     and treatment strategies.




                                             39
              MEMORIAL HERMANN MEDICAL INTENSIVE CARE UNIT

The Memorial Hermann Hospital Intensive Care Unit (MICU) is a 16-bed unit specializing in the
care of medically critically ill patients from a wide spectrum of medical and neurologic
etiologies. Conditions cared for in the MICU include but are not limited to: acute hypoxia, acute
respiratory distress syndrome, acid-base imbalances, liver and renal failure, acute stroke,
intracranial hemorrhage, status epilepticus, and coma. Rotations in the MICU are one month in
length, and the unit is staffed with three residents and three interns. Call on the rotation is every
fourth night, and there is one day off during the week. Those residents assigned to the MICU are
exempt from Morning Report, but are required to attend Noon Conferences.

The residents work closely with the Pulmonary/Critical Care Attending and Fellow during this
month, and have the opportunity to learn procedures under the direct supervision of the MICU
Attending and Fellow such as thoracentesis, lumbar puncture, intubation and placement of
central venous catheters/arterial lines. Residents may have the opportunity to participate in the
placement of Swan-Ganz catheters; in all cases the MICU Attending or another
Pulmonary/Critical Care Attending is present for the entire procedure.

Patients seen on the Memorial Herman Medical Intensive Care Unit rotation include patients
admitted to the MICU, patients transferred from an internal medicine service, patients admitted
directly to the MICU from the ER, and patients transferred to Memorial Hermann MICU from
outside hospitals.

  Legend for Learning Activities
  AR – Attending Rounds       DSP – Directly Supervised             M&M-Morbidity & Mortality
                              Procedures                            MP – Med/Path Conference
  Au – Autopsy Report         EBM - Evidence Based Med              MR – Morning Report
  CR – Chairman’s Rounds      FS – Faculty Supervision              NC – Noon Conferences
  CPC–Clinicopathologic       GR – Grand Rounds                     PathCl- Path for Clinicians
   Conf.                                                            PC–Professionalism Curriculum
  CC-Core Curriculum          IL-Introductory Lecture Series        SS – Senior Seminar
  DPC – Direct Patient Care   JC – Journal Club                     LL – Lunch & Learn Series
                              MJ – Medical Jeopardy

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations            PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures  PR – Peer Review
  MR – Morning Report                   TYPD – Transitional Year Program Director




                                                 40
Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal. A detailed description
of the on-going learning activities at Memorial Hermann Hospital is included near the front of the
report for further information.

A. Patient Care

                                                                     Learning               Evaluation
         Principal Educational Goals
                                                                     Activities             Methods
   1.    Ability to take a complete medical history and                                     AE
                                                                     DPC, AR
         perform a careful and accurate physical examination
   2.    Ability to write concise, accurate and informative                                 AE
                                                                     DPC, AR
         histories, physical examinations and progress notes.
   3.    Effectively evaluate and manage patients with critical                             AE
                                                                     DPC, CC, GR,
         medical illness, including those on mechanical
                                                                     NC
         ventilation and vasopressors.
   4.    Effectively evaluate and manage patients with critical                             AE
                                                                     DPC
         neurological illness.
   5.    Ability to formulate comprehensive and accurate                                    AE
                                                                     DPC, AR, CC,
         problem lists, differential diagnoses and plans of
                                                                     GR
         management for a critically ill patient
   6.    Insert central venous lines and arterial lines with                                AE, DSP,
                                                                     DSP, LL
         proper technique.                                                                     TYPD
   7.    Ability to perform basic procedures: venipuncture,
         arterial puncture, placement of central venous lines,       DPC, AR, DSP           AE, DSP
         lumbar puncture, abdominal paracentesis,
         thoracentesis, arthrocentesis, and nasogastric
         intubation.

   8.    Ability to perform endotracheal intubation under            DSP, DPC               AE, DSP
         close supervision.


   9.    Ability to perform basic ventilator management.             DSP, AR, LL            AE, TYPD


   10. Insertion and basic management of pulmonary arterial                                 AE, DSP
                                                            DPC, DSP, AR
       catheters under close supervision.




                                                   41
  11. Ability to make basic interpretation of chest and                            AE
                                                                 DPC, AR
      abdominal x-rays and electrocardiograms.


  12. Ability to perform cardiopulmonary resuscitation and       DSP, DPC, AR,     AE
      advanced cardiac life support.                               LL



  13. Participation in and later leadership of discussion of                       AE, TYPD
                                                                 DPC, AR, PC, LL
      end-of-life issues with families.


B. Medical Knowledge

                                                                 Learning          Evaluation
       Principal Educational Goals
                                                                 Activities        Methods
  1.   Expand clinically applicable knowledge base of the        DPC, AR, CC,      AE
       basic and clinical sciences underlying the care of        NC, GR
       patients with critical medical and neurological illness
  2.   Access and critically evaluate current medical            DPC, SS           AE
       information and scientific evidence relevant to
       medical and neurological critical care
  3.   Understand the physiologic and pathophysiologic           DPC, DSP          AE
       principles of invasive hemodynamic monitoring
       including indications
  4.   Understanding the basic pathophysiology, clinical         DPC, AR, CC
       manifestations, diagnosis and management of severe                          AE
       and life-threatening medical illnesses.
                                                                                   AE
  5.   Familiarity with the basic principles of ventilator       DPC, AR, CC       AE
       management.

  6.   Familiarity with the basic principles of                  DPC, AR, CC       AE
       pathophysiology, diagnosis and management of
       respiratory failure.

  7.   Familiarity with the basic principles of            DPC, AR, CC             AE
       pathophysiology, diagnosis and management of sepsis
       and the syndrome of multiple organ failure.


  8.   Familiarity with indications for performance and
       basic interpretation of blood counts, coagulation         DPC, AR, CC
       studies, blood chemistry tests, urinalysis, body fluid                      AE

                                               42
        analyses, microbiologic tests, spirometry and arterial
        blood gases.
  9.    Basic familiarity with indications for and               DPC, AR           AE
        interpretation of chest and abdominal X-ray,
        electrocardiograms, and pulmonary function tests.


C. Interpersonal Skills and Communication

                                                                 Learning          Evaluation
        Principal Educational Goals
                                                                 Activities        Methods
  1.    Communicate effectively with patients and families in
        a stressful critical care environment, including      DPC, AR, PC          AE
        discussion of end-of-life issues and limits of care.
  2.    Communicate effectively with physician colleagues
        and members of other health care professions to       DPC, AR, PC          AE, PR
        assure timely, comprehensive patient care
  3.    Communicate effectively with colleagues when
        signing out DPC, TR patients or turning over care to  DPC                  AE, PR
        another service

D. Professionalism

                                                                 Learning          Evaluation
         Principal Educational Goals
                                                                 Activities         Methods
   1.    Interact professionally toward patients, families,
                                                                 DPC, AR, PC
         colleagues, and all members of the health care team.                      AE, PR
   2.    Acceptance of professional responsibility as the
         primary care physician for patients under his/her       DPC, AR, PC       AE, PR
         care.
   3.    Appreciation of the social context of illness.          DPC, AR, PC       AE, PR


E. Practice-Based Learning and Improvement

                                                                 Learning          Evaluation
        Principal Educational Goals
                                                                 Activities        Methods
   1.   Identify and acknowledge gaps in personal
        knowledge and skills in the care of patients with        DPC, AR           AE
        critical medical and neurological illness
   2.   Develop real-time strategies for filling knowledge
        gaps that will benefit patients in the medical           DPC, AR           AE
        intensive care unit
   3.   Commitment to professional scholarship, including        AR, JC, SS, EBM   AE

                                                43
     systematic and critical perusal of relevant print and
     electronic literature, with emphases on integration of
     basic science with clinical medicine, and evaluation
     of information in light of the principles of evidence-
     based medicine

F. Systems-Based Practice

                                                                Learning       Evaluation
     Principal Educational Goals
                                                                Activities     Methods
1.   Understand and utilize the multidisciplinary
     resources necessary to care optimally for critically ill   DPC, AR        AE
     medical and neurological patients.
2.   Collaborate with other members of the health care
     team to assure comprehensive care for patients with        DPC, AR, PC    AE, PR
     critical medical and neurological illness.
3.   Use evidence-based, cost-conscious strategies in the
                                                                DPC, JC, SS,
     care of patients with critical medical and                                AE
                                                                EBM
     neurological illness.
4.   Knowing when to consult a medical subspecialist.           DPC, AR        AE
5.  Knowing when to ask for help and advice from                               AE, PR
                                                                DPC, AR
    senior residents and attending physicians
6. Effective professional collaboration with residents,                        AE, PR
    fellows and faculty consultants from other                  DPC, PC
    disciplines such as Radiology and Surgery.
7. Learning by participation in ward rounds, teaching                          AE
                                                                DPC
    conferences and other educational activities.
8. Effective collaboration with other members of the            DPC, PC        AE, PR
    health care team, including residents at all levels,
    medical students, nurses, clinical pharmacists,
    occupational therapists, physical therapists, nutrition
    specialists, patient educators, speech pathologists,
    respiratory therapists, enterostomy nurses, social
    workers, case managers, discharge planners, clinical
    pharmacists and providers of home health services.
9. Effective utilization of medical consultants,                               AE, PR
    including knowing when and how to request
                                                                DPC
    consultation, and how best to utilize the advice
    provided.
10. Consideration of the cost-effectiveness of diagnostic                      AE
                                                                DPC
    and treatment strategies.




                                             44
                       MEMORIAL HERMANN CORONARY CARE UNIT (CCU)
                             AND CARDIOLOGY WARD SERVICE

The Memorial Hermann Hospital Coronary Care Unit (CCU) and Cardiology Ward Service rotation is a
one month rotation, and consists of a team of four residents and four interns. Residents and interns take
call every fourth night, and have one day a week off. During the rotation, team members have an
opportunity to learn procedures under the direct supervision of the CCU attending or fellow.

Patients seen on the Memorial Hermann Hospital CCU and the Cardiology Ward Service
include patients of faculty physicians, unassigned patients admitted to from the clinics or ER, and a select
group of patients of community physicians who are authorized to admit patients to these services. During this
rotation, residents attend the scheduled cardiology conferences which are offered while they are on the service.
 Residents are excused from Morning Report, but are required to attend the Department of Medicine Core
Curriculum lectures which are held during their rotation.

  Legend for Learning Activities
  AR – Attending Rounds          DSP – Directly Supervised                 M&M-Morbidity & Mortality
                                 Procedures                                MP – Med/Path Conference
  Au – Autopsy Report            EBM - Evidence Based Med                  MR – Morning Report
  CR – Chairman’s Rounds         FS – Faculty Supervision                  NC – Noon Conferences
  CPC–Clinicopathologic          GR – Grand Rounds                         PathCl- Path for Clinicians
   Conf.                         IL-Introductory Lecture Series            PC–Professionalism Curriculum
  CC-Core Curriculum             JC – Journal Club                         SS – Senior Seminar
  DPC – Direct Patient Care      MJ – Medical Jeopardy                     LL – Lunch & Learn Series


  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                                  PR – Peer Review
  PDR–Program Director’s Review (quarterly)


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists
the goal, the third column lists the most relevant learning activities for that goal, and the fourth column
indicates the correlating evaluation methods for that goal.

A. Patient Care

         Principal Educational Goals                                      Learning                Evaluation
                                                                          Activities              Methods
 1.      Take a complete medical history and perform a careful and
                                                                          DPC, AR
         accurate physical examination with a cardiology focus.                                   AE
 2.      Ability to recognize the physical findings of chronic                                    AE
         congestive heart failure, acute pulmonary edema, mitral
                                                                          DPC, AR
         regurgitation, mitral stenosis, aortic stenosis, aortic
         regurgitation and tricuspid regurgitation.
 3.      Write concise, accurate and informative histories, physical                              AE
                                                                          DPC, AR
         examinations and progress notes with a cardiology focus.

                                                      45
4.     Ability to formulate comprehensive and accurate problem
       lists, differential diagnoses and plans of management for     DPC, AR, CC        AE
       patients with acute cardiac illness.
5.     Effectively evaluate and manage patients with acute
       cardiac illness; particularly acute coronary syndromes,
                                                                     DPC, AR, CC
       acute myo-cardial infarction, congestive heart failure,                          AE
       pulmonary edema and acute valvular heart disease.
6.     Effectively manage patients with undiagnosed chest pain,
                                                                     DPC, AR, CC
       including the appropriate use of diagnostic testing.                             AE
8.                                                                                      AE
                                                                     DPC, AR, CC
       Ability to interpret electrocardiograms and rhythm strips.

9.     Effectively evaluate and manage patients who have                                AE
                                                                     DPC, AR, DSP
       undergone interventional procedures.
10.    Ability to perform basic ventilator management.               DPC, AR, DSP, LL   AE,TYPD

13.    Ability to perform CPR and advanced cardiac life support.     DPC, DSP, PC, LL   AE,TYPD

14.    Willingness and ability to help patients undertake basic
       strategies for prevention of cardiovascular disease,                             AE
                                                                     DPC, AR
       including modifications of diet and physical activity, and
       cessation of use of tobacco.
15.    Participation in and later leading of discussion of end-of-                      AE, TYPD
                                                                     DPC, AR, PC, LL
       life issues with families.
16.    Insert central venous lines and arterial lines with proper                       AE,TYPD
                                                                     DPC, DSP, AR, LL
       technique.


B. Medical Knowledge

                                                                     Learning           Evaluation
       Principal Educational Goals
                                                                     Activities         Methods
1.     Expand clinically applicable knowledge base of the basic
       and clinical sciences underlying the care of patients with    DPC, AR            AE
       chest pain and acute cardiac disease.
2.     Access and critically evaluate current medical information
                                                                     DPC, AR
       and scientific evidence relevant to acute cardiac care.                          AE
3.     Understand indications for aggressive anticoagulant and
       antiplatelet therapy as well as the mechanisms of action of   DPC, AR            AE
       the various agents.
4.     Understand the physiologic and pathophysiologic
       principles of invasive hemodynamic monitoring including       DPC, AR            AE
       indications.
5.     Understanding the basic pathophysiology, clinical                                AE
       manifestations, diagnosis and management of cardiac           DPC, AR
       diseases, as seen on a coronary care unit.
6.     Familiarity with the basic principles of diagnosis and        DPC, AR            AE
       management of essential hypertension; ischemic heart
       disease, including unstable angina pectoris and myocardial

                                                   46
       infarction; congestive heart failure; common cardiac
       arrhythmias, especially atrial fibrillation, supraventricular
       tachycardia, and ventricular arrhythmias; common
       rheumatic heart diseases; common congenital heart
       diseases.
 7.     Basic familiarity with the indications for, principles,        DPC, AR           AE
       complications, and elementary interpretation of ECG,
       inpatient rhythm monitoring, exercise and chemical stress
       tests, electrophysiologic studies, transthoracic and
       transesophageal cardiac ECHO, nuclear cardiac imaging,
       right and left ventricular catheterization, coronary
       angiography, and percutaneous angioplasty.
 8.     Familiarity with basic principles of assessment of lifetime                      AE
                                                                       DPC, AR
       cardiovascular risk & cardiovascular risk prevention.
 9.     Familiarity with basic strategies for cessation of use of                        AE
                                                                       DPC, AR
       tobacco.

C. Interpersonal Skills and Communication

                                                                       Learning          Evaluation
       Principal Educational Goals
                                                                       Activities        Methods
 1.    Communicate effectively with patients and families in a                           AE, TYPD
                                                                       DPC, AR, LL
       stressful critical care environment.
 2.    Communicate effectively with physician colleagues and
       members of other health care professions to assure timely,      DPC, AR           AE, PR
       comprehensive patient care.
 3.    Communicate effectively with colleagues when signing out
                                                                       DPC, AR
       DPC or turning over care to another service.                                      AE, PR

D.     Professionalism

       Principal Educational Goals                                     Learning          Evaluation
                                                                       Activities        Methods
 1.    Interact professionally toward towards patients, families,
                                                                       DPC, AR
       colleagues, and all members of the health care team.                              AE, PR
 2.    Interacting with patients and families in a professionally                        AE
                                                                       DPC, AR
       appropriate manner.
 3.    Acceptance of professional responsibility as the primary
                                                                       DPC, AR
       care physician for patients under his/her care.                                   AE, PR
 4.    Appreciation of the social context of illness.                  DPC, AR           AE

 5.    Effective utilization of ethics knowledge and consultants.
       This includes guidelines for CPR and DNR and end of life        DPC, AR, PC, LL   AE, TYPD
       cardiac care.




                                                   47
E. Practice-Based Learning and Improvement

                                                                           Learning      Evaluation
         Principal Educational Goals
                                                                           Activities    Methods
 1.      Identify and acknowledge gaps in personal knowledge and
                                                                           DPC, AR
         skills in the care of acute cardiac patients.                                   AE
 2.      Develop real-time strategies for filling knowledge gaps that
                                                                           DPC, AR
         will benefit patients in the coronary care unit.                                AE
 3.      Commitment to professional scholarship, including
                                                                           DPC, AR
         systematic and critical perusal of relevant print and                           AE
         electronic literature, with emphases on integration of basic
         science with clinical medicine, and evaluation of
         information in light of the principles of evidence-based
         medicine.


      F. Systems-Based Practice

                                                                           Learning      Evaluation
         Principal Educational Goals
                                                                           Activities    Methods
 1.      Understand and utilize the multidisciplinary resources
                                                                           DPC, AR
         necessary to care optimally for acutely ill cardiac patients.                   AE
 2.      Collaborate with other members of the health care team to                       AE, PR
                                                                           DPC, AR
         assure comprehensive coronary care.
 3.      Use evidence-based, cost-conscious strategies in the care of
                                                                           DPC, AR
         patients with chest pain and other acute cardiac disease.                       AE
 4.      Knowing when to ask for help and advice from senior                             AE, PR
                                                                           DPC, AR
         residents and attending physicians.
 5.      Effective professional collaboration with residents, fellows
         and faculty consultants from other disciplines such as            DPC, AR, GR   AE
         Radiology and Surgery.
 6.      Learning by participation in ward rounds, teaching                              AE
                                                                           DPC, AR
         conferences and other educational activities.
 7.      Effective collaboration with other members of the health
                                                                           DPC, AR
         care team, including residents at all levels, medical students,                 AE, PR
         nurses, clinical pharmacists, occupational therapists,
         physical therapists, nutrition specialists, patient educators
         ech pathologists, respiratory therapists, enterostomy nurses,
         social workers, case managers, discharge planners, clinical
         pharmacists and providers of home health services.
 8.      Effective utilization of ethics consultants, including            DPC, AR, PC   AE
         knowing when and how to request consultation, and how
         best to utilize the advice provided.
 9.      Consideration of the cost-effectiveness of diagnostic and                       AE
                                                                           DPC, AR
         treatment strategies.




                                                      48
           MEMORIAL HERMANN AND LBJ RENAL INPATIENT SERVICE

The Memorial Hermann Renal Inpatient Service is a month long rotation for one upper level
resident and two or three interns. The rotation is run by a Nephrology attending and a fellow.
Patients seen include inpatients with renal insufficiency, nephrotic syndrome, nephritis, and end-
stage renal disease. Though this is a ward service, the residents do not take call, they have one
day off a week, and they do not participate in the nephrology clinic. Admissions are taken daily
until 5 PM during weekdays and noon on weekends. After hour admissions are taken by the float
resident.

  Legend for Learning Activities
  ACS – Ambulatory Care       DPC – Direct Patient Care               M&M-Morbidity & Mortality
   Series                     DSP – Directly Supervised               MR – Morning Report
  AR – Attending Rounds       Procedures                              NC – Noon Conferences
                              FS – Faculty Supervision                PC–Professionalism Curriculum
  Au – Autopsy Report         GR – Grand Rounds                       RC – Research Conference
  CR – Chairman’s Rounds                                              SS – Senior Seminar
  CPC–Clinicopathologic       IL-Introductory Lecture Series          SL – Subspecialty Lectures
   Conf.                      JC – Journal Club                       LL – Lunch & Learn Series
  CC-Core Curriculum          MJ – Medical Jeopardy

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations            PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures  PR – Peer Review
  MR – Morning Report                   TYPD – Transitional Year Program Director


Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.


A. Patient Care

                                                                     Learning               Evaluation
        Principal Educational Goals
                                                                     Activities             Methods
  3.    Ability to take a complete medical history and perform                              AE
        a careful and accurate physical examination with a     DPC, AR, MR
        nephrology focus.


                                                   49
 2.    Ability to write concise, accurate and informative                        AE
      histories, physical examinations and progress notes       DPC, AR
      with a nephrology focus.
 3.   Define and prioritize patients’ medical problems and                       AE
                                                                DPC, AR, MR
      generate appropriate differential diagnoses.
 4.   Develop rational, evidence-based management               DPC, AR, MR,     AE
      strategies.                                               PC
 5.   Ability to make an appropriate differential diagnosis     DPC, AR, SL      AE
      and plan of management for patients with acute renal
      insufficiency and oliguria.
 6.   Ability to perform basic procedures: venipuncture,        DPC, AR, LL      AE, TYPD
      arterial puncture, placement of central venous lines,
      lumbar puncture, abdominal paracentesis,
      thoracentesis, arthrocentesis, and nasogastric
      intubation.


 7.   Participation and later leadership of discussions of      DPC, AR, PC, LL AE, TYPD
      end-of-life issues with families.

B. Medical Knowledge

                                                                Learning         Evaluation
      Principal Educational Goals
                                                                Activities       Methods
 1.   Expand clinically applicable knowledge base of the
                                                                DPC, AR, CR,
      basic and clinical sciences underlying the care of                         AE
                                                                MR, NC, GR, SL
      medical patients.
 2.   Access and critically evaluate current medical
                                                                DPC, AR, JC,
      information and scientific evidence relevant to patient                    AE
                                                                MR, GR, SL
      care.
 3.   Understanding the basic elements of                       DPC, AR, MR,
      pathophysiology, diagnosis and management of              NC, GR, SL       AE
      important renal diseases, including those caused by
      hypertension, immune mechanisms, diabetes,
      infection, drug toxicity, nephrotic syndrome,
      disorders of tubular function and urinary obstruction.

 4.
      Familiarity with evaluation and basic management of       DPC, AR          AE
      patients with chronic and acute renal failure.




                                               50
 5.    Familiarity with the cardiovascular, metabolic,
       infectious, skeletal, endocrine, immunologic,                               AE
                                                                DPC, AR, SL
       hematologic and gastrointestinal complications of
       chronic renal failure.
 6.                                                             DPC, AR, GR,       AE
       Familiarity with indications for performance and         SL
       basic interpretation of specialized tests of renal
       function.

 7.
       Basic familiarity with the indications, principles and   DPC, AR, SL
                                                                                   AE
       important medical complications of hemodialysis,
       peritoneal dialysis and renal transplantation.


 8.    Recognize the indications of basic interpretation of     DPC, CC            AE
       chest and abdominal X-rays, electrocardiograms, and
       pulmonary function tests.


 9.    Learn indications for and basic interpretation of        DPC, AR, MR,       AE
       standard laboratory tests, including blood counts,       GR
       coagulation students, blood chemistry tests,
       urinalysis, body fluid analyses, and microbiologic
       tests.


C. Interpersonal Skills and Communication

                                                                Learning           Evaluation
       PRINCIPAL EDUCATIONAL GOALS
                                                                Activities         Methods
  1.                                                            DPC, AR, CR, PC,   AE, TYPD
       Communicate effectively with patients and families.
                                                                LL
  2.   Communicate effectively with physician colleagues at     DPC, AR, CR,       AE, PR
       all levels.                                              MR, PC
  3.   Communicate effectively with all non-physician
       members of the health care team to assure                                   AE
                                                                DPC, AR, PC
       comprehensive and timely care of hospitalized
       patients.
  4.   Present information on patients concisely and clearly    DPC, AR, CR,       AE
       both verbally and in writing.                            MR




                                               51
D. Professionalism

                                                                  Learning         Evaluation
       Principal Educational Goals
                                                                   Activities      Methods
  1.   Interact professionally with patients, families,                           AE, PR,
                                                                  DPC, AR, MR, LL
       colleagues, and all members of the health care team.                          TYPD
  2.   Appreciation of the social context of illness.             DPC, AR, MR, PC AE

E. Practice-Based Learning and Improvement

                                                                  Learning         Evaluation
       Principal Educational Goals
                                                                  Activities       Methods
 1.    Identify and acknowledge gaps in personal knowledge
                                                                  DPC, AR, MR
       and skills in the care of hospitalized patients.                            AE
 2.    Develop and implement strategies for filling gaps in                        AE
                                                                  JC, SS, NC
       knowledge and skills.
 3.    Commitment to professional scholarship, including                           AE
                                                                  DPC, AR, MR,
       systematic and critical perusal of relevant print and
                                                                  JC, NC, SS
       electronic literature, with emphases on integration of
       basic science with clinical medicine, and evaluation
       of information in light of the principles of evidence-
       based medicine.


F. Systems-Based Practice

                                                                                    Evaluation
                                                                  Learning
        Principal Educational Goals
                                                                  Activities       Methods
  1.    Understand and utilize the multidisciplinary resources
                                                                  DPC, MR, AR
        necessary to care optimally for hospitalized patients.                     AE
  2.    Collaborate with other members of the health care                          AE
                                                                  DPC, MR, AR
        team to assure comprehensive patient care.
  3.    Understanding when to ask for help and advice from                         AE, PR
                                                                  DPC, AR
        senior residents and attending physicians.
  4.    Effective collaboration with other members of the                          AE, PR
                                                                  DPC, AR, MR
        health care team, including residents at all levels,
        medical students, nurses, clinical pharmacists,
        occupational therapists, physical therapists, nutrition
        specialists, patient educators, speech pathologists,
        respiratory therapists, enterostomy nurses, social
        workers, case managers, discharge planners, clinical
        pharmacists and providers of home health services.


                                                52
5.   Knowing when and how to request medical
     consultation, and how best to utilize the advice        DPC, AR       AE
     provided.
6.   Knowing when and how to request ethics
     consultation, and how best to utilize the advice        DPC, AR, PC   AE
     provided.
7.   Consideration of the cost-effectiveness of diagnostic                 AE
                                                             DPC, AR, MR
     and treatment strategies.
8.   Learning by participation in ward rounds, teaching
                                                             DPC, MR, NC
     conferences and other educational activities.                         AE




                                            53
             M.D. ANDERSON HEMATOLOGY CONSULTATION SERVICE

The M.D. Anderson Hematology consultation service is a month long rotation for one resident
and two interns. The trainees are part of a Hematology inpatient consult service with daily
rounding under the supervision of a full-time M.D. Anderson hematology faculty. The rotation
has a Monday through Friday schedule. In addition the residents and interns manage patients in
both Hematology and Oncology outpatient clinics. During a typical week each resident or intern
will have two half day hematology clinics and two half day oncology clinics. Overnight call
occurs every one in five nights with coverage of patients with solid tumors at M.D. Anderson
Cancer Center. The residents do not take admissions during call. Residents have regular
didactic teaching sessions at M.D. Anderson and attend conferences at M.D. Anderson except for
the Core Curriculum conference, which they are required to attend at Memorial Hermann
Hospital.

Didactic Teaching Schedule Example:

            Mon    12:00PM     Fellows Office     Didactic Teaching Session
            Tues   8:00AM      Hickey Rose 11     Cancer Medicine Grand Rounds
            Tues   12:00PM     See schedule       Fellows’ Didactic Lecture Series
            Wed    12:00PM     Fellows Office     Didactic Teaching Session
            Thur   12:00PM     See schedule       Fellows’ Didactic Lecture Series
            Fri    12:00PM     Hickey Rose 11     Institutional Grand Rounds

Monthly Schedule Example:

                   Resident              Intern                    Intern
Monday AM          Gonzalez (Breast)     Hematology Rounds         Hematology Rounds
Monday PM          Gonzalez (Breast)     Hematology Consults       Hematology Consults
Tuesday AM         Hematology Rounds     Varadhachary (GI)         Hematology Rounds
Tuesday PM         Hematology Consults   Varadhachary (GI)         Hematology Consults

Wed     AM         Hematology Rounds     Hematology Rounds
                                                                   Moulder (Breast)
Wed     PM         Hematology Consults   Hematology Consults
                                                                   Moulder (Breast)
Thursday AM        Juneja (Hematology)   Juneja (Hematology)       Juneja (Hematology)
Thursday PM        Continuity Clinic     Hematology Rounds         Hematology Rounds
                   Kroll/Afshar          Kroll/Afshar              Kroll/Afshar
Friday AM
                   (Hematology)          (Hematology)              (Hematology)
Friday PM
                   Hematology Rounds     Hematology Rounds         Hematology Rounds




                                             54
  Legend for Learning Activities
  MC – Morning Conference                          DSP – Directly Supervised Procedures
  TTC – Tuesday /Thursday Conferences              CC – Core Curriculum (Hermann)
  WC – Wednesday Conference                        AR – Attending Rounds
  DPC – Direct Patient Care

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                              PR – Peer Review
  PDR–Program Director’s Review (quarterly)


Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal. A detailed
description of the on-going learning activities at M.D. Anderson Cancer Center is included in the
front of the report for further information.



A. Patient Care

                                                                    Learning               Evaluation
        Principal Educational Goals
                                                                    Activities             Methods
  4.    Ability to take a complete medical history and                                     AE
                                                                    DPC, MC, NC,
        perform a careful and accurate physical examination
                                                                    TTC, WC
        of cancer patients in the ambulatory setting.
  2.    Ability to write concise, accurate and informative                                 AE
                                                                    DPC, MC, NC,
        histories, physical examinations and progress notes of
                                                                    TTC, WC
        cancer patients.
  3.    Define and prioritize patients’ medical problems and        DPC, MC, NC,           AE
        generate appropriate differential diagnoses.                TTC, WC
  4.     Ability to make appropriate diagnostic and treatment       DPC, MC, NC,           AE
        plans for patients with newly diagnosed cancer.             TTC, WC
  5.    Ability to make basic interpretation of imaging                                    AE
                                                                    DPC, MC, NC,
        studies, including X-rays of chest and abdomen;
                                                                    TTC, WC
        CT scans of brain, chest, abdomen and pelvis.




                                                  55
B. Medical Knowledge

                                                                 Learning       Evaluation
       Principal Educational Goals
                                                                 Activities     Methods
 1.    Understand basic pathophysiology, clinical                               AE
                                                                 DPC, MC, NC,
       manifestations, diagnosis and management of
                                                                 TTC, WC
       common types of cancer as seen in the ambulatory
       setting.
 2.    Familiarity with the basic principles of medical care     DPC, MC, NC,   AE
       of patients with cancer.                                  TTC, WC
 3.    Familiarity with the basic principles of initial                         AE
       evaluation and treatment planning for patients with       DPC, MC, NC,
       newly discovered cancer as seen in the ambulatory         TTC, WC
       setting.
 4.    Familiarity with the basic principles of action and       DPC, MC, NC,   AE
       major side effects of chemotherapeutic drugs.             TTC, WC
 5.    Familiarity with the basic principles of evaluation and   DPC, MC, NC,   AE
       staging of cancer, and determination of prognosis.        TTC, WC
 6.    Basic familiarity with indications for and                               AE
       interpretation of chest and abdominal X-rays, CT          DPC, MC, NC,
       scans of brain, chest, abdomen and pelvis, and            TTC, WC
       electrocardiograms.
 7.    Learn indications for and basic interpretation of                        AE
       standard laboratory tests, including blood counts,
                                                                 DPC, MC, NC,
       coagulation students, blood chemistry tests,
                                                                 TTC, WC
       urinalysis, body fluid analyses, and microbiologic
       tests.

C. Interpersonal Skills and Communication

                                                             Learning           Evaluation
       PRINCIPAL EDUCATIONAL GOALS
                                                             Activities         Methods
  1.   Communicate effectively with cancer patients and      DPC, MC, NC,       AE
       their families.                                       TTC, WC
  2.   Communicate effectively with physician colleagues at DPC, MC, NC,        AE
       all levels.                                           TTC, WC
  3.   Present information on patients concisely and clearly DPC, MC, NC,       AE
       both verbally and in writing.                         TTC, WC




                                              56
D. Professionalism

                                                                Learning        Evaluation
       Principal Educational Goals
                                                                 Activities     Methods
 1.    Interact professionally toward towards patients,                        AE
       families, colleagues, and all members of the health care DPC, MC, NC,
       team.                                                    TTC, WC
 2.                                                             DPC, MC, NC,   AE
       Appreciation of the social context of illness.
                                                                TTC, WC

E. Practice-Based Learning and Improvement

                                                                Learning        Evaluation
       Principal Educational Goals
                                                                Activities     Methods
 1.    Develop and implement strategies for filling gaps in     DPC, MC, NC,   AE
       knowledge and skills.                                    TTC, WC
 2.    Commitment to professional scholarship, including        DPC, MC, NC,   AE
       systematic and critical perusal of relevant print and    TTC, WC
       electronic literature, with emphases on integration of
       basic science with clinical medicine, and evaluation
       of information in light of the principles of evidence-
       based medicine.


F. Systems-Based Practice

                                                                                Evaluation
                                                                Learning
       Principal Educational Goals
                                                                Activities     Methods
  1.   Effective professional collaboration with residents,     DPC, MC, NC,   AE
       fellows and faculty consultants from other disciplines   TTC, WC
       such as Radiology and Surgery.
  2.                                                            DPC, MC, NC,   AE
       Effective collaboration with other members of the
                                                                TTC, WC
       health care team, including nurses, social workers,
       case managers, and clinical pharmacists.
  3.   Knowing when and how to request medical                  DPC, MC, NC,   AE
       consultation, and how best to utilize the advice         TTC, WC
       provided.
  4.   Knowing when and how to request ethics                                  AE
                                                                DPC, MC, NC,
       consultation, and how best to utilize the advice
                                                                TTC, WC
       provided.
  5.   Consideration of the cost-effectiveness of diagnostic    DPC, MC, NC,   AE
       and treatment strategies.                                TTC, WC

                                               57
6.   Learning by participation in teaching conferences and   DPC, MC, NC,   AE
     other educational activities.                           TTC, WC




                                           58
                                     LBJ EMERGENCY MEDICINE
                                      LBJ EMERGENCY CENTER

The LBJ Emergency Medicine rotation has five to seven interns assigned to the Emergency Room at LBJ,
and three to four residents assigned. There is a Holding Area for patients for 23 hour observation. All
patients sent to the Holding Area are followed by the resident/intern who initially saw them. Residents
manage all critical patients and routine minor surgical care such as lacerations and kidney stones. The
rotation is one month long. Interns and residents work 19 twelve hour shifts per month and 9 twelve hour
shifts per two week rotation. Half the shifts are days and half are nights. Supervision in the Emergency
Room is by full-time faculty in our Department of Emergency Medicine. Residents perform initial
evaluations of adult patients presenting to the Emergency Room with undifferentiated medical problems in
this rotation. Residents and interns attend a weekly conference on Wednesday morning which covers
various emergency medicine topics as well as a monthly M&M conference, interpretation of
electrocardiograms and journal club (quarterly).

  Legend for Learning Activities
  AR – Attending Rounds          DrFR – Dr. Fred Rounds                     MP – Med-Path Conference
                                 EBM-Evidence Based Medicine                MedRad –Med-Rad Conf.
  CPC–Clinicopathologic          FS – Faculty Supervision                   MR – Morning Report
   Conf.                         GR – Grand Rounds                          NC – Noon Conferences
  CC-Core Curriculum             IL-Introductory Lecture Series             PathCl-Pathology Clinicians
  DPC – Direct Patient Care      MJ – Medical Jeopardy                      SS – Senior Seminar
  DSP – Directly Supervised      LL-Lunch and Learn                         EMC-Emergency Medicine
    Procedures                   DO H&P –Direct observation of              Conference
  JC-Journal Club                an H&P (adult and pediatrics-
                                 twice yearly)

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                  PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures        PR – Peer Review
  MR – Morning Report                         TYPD-TY Program Director


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.


A. Patient Care

                                                                            Learning               Evaluation
          Principal Educational Goals
                                                                            Activities             Methods
 1.       Effectively perform initial evaluation and management of          DPC, FS, CC,
                                                                                                   AE
          patients with medical emergencies.                                EMC, NC
 2.       Effectively assess patients’ need for hospital admission and      DPC, FS, CC,
                                                                                                   AE
          appropriate level of inpatient care.                              EMC, NC

                                                       59
 3.     Know indications for common emergency department                DPC, DSP, FS, IL,
                                                                                            AE,
        procedures and perform these procedures with proper             CC, EMC,NC, LL
                                                                                            DSP,TYPD
        technique.
 4.                                                                     DPC, FS, IL,
        Ability to take a complete medical history and perform a
                                                                        EMC,NC, CC, DO      AE, TYPD
        careful and accurate physical examination.
                                                                        H&P
 5.     Ability to write concise, accurate and informative histories,   DPC, FS, IL,
                                                                                            AE
        physical examinations and progress notes.                       EMC,NC, CC
 6.                                                                     DPC, FS, IL, CC,    AE
        PG-1 - Ability to make basic interpretation of chest and        NC
        abdominal x-rays, and electrocardiograms.

 7.                                                                     DPC, DSP, FS, LL    AE,
                                                                                            DSP,TYPD
        PG-1 - Ability to perform basic procedures: venipuncture,
        arterial puncture, placement of central venous lines, lumbar
        puncture, abdominal paracentesis, thoracentesis,
        arthrocentesis, and nasogastric intubation.



 8.     Ability to perform endotracheal intubation under close          DPC, DSP, FS,LL     AE,
        supervision.                                                                        DSP,TYPD
 9.     Ability to perform cardiopulmonary resuscitation and            DPC, DSP, FS, IL,
                                                                                            AE,
        advanced cardiac life support, including application of         CC, LL
                                                                                            DSP,TYPD
        electrodes for defibrillation and external pacing.
 10.    PG-1 - Ability to perform pelvic examination under              DPC,DSP,FS
        supervision.                                                                        DSP




B. Medical Knowledge

                                                                        Learning            Evaluation
        Principal Educational Goals
                                                                        Activities          Methods
 1.     Expand clinically applicable knowledge base of the basic
                                                                        DPC, FS, CC, IL,
        and clinical sciences underlying the care of patients with                          AE
                                                                        EMC,NC
        medical emergencies.
 2.     Access and critically evaluate current medical information
                                                                        DPC, JC, GR         AE
        and scientific evidence relevant to medical emergency care.
 3.                                                                     DPC, FS, CC, IL,
        PG-1 - Understanding the basic pathophysiology, clinical                            AE
                                                                        EMC
        manifestations, diagnosis and management of acute and
        emergent presentations of medical illnesses, including
        myocardial infarction, aortic dissection, seizure disorders,
        gastrointestinal hemorrhage, alcohol withdrawal,
        decompensated diabetes, exacerbations of asthma and
        chronic obstructive lung disease, meningitis, drug
        overdosage and poisoning.


                                                   60
4.    PG-1 - Familiarity with basic pathophysiology, clinical        DPC, FS, CC, IL,
                                                                                        AE
      manifestations, diagnosis and management of common             EMC
      gynecologic emergencies, including rape, vaginal bleeding,
      spontaneous abortion, acute salpingitis, and pregnancy
      induced hypertension.

5.    PG-1 - Familiarity with basic pathophysiology, clinical        DPC, FS, CC, IL,   AE
      manifestations, diagnosis and management of common             EMC, LL
      ophthalmologic emergencies, including ocular injuries and
      conjunctivitis.
      .
6.                                                                   DPC, FS, CC, IL,   AE
      PG-1 - Familiarity with basic pathophysiology, clinical
                                                                     EMC
      manifestations, diagnosis and management of common
      musculoskeletal emergencies, including non-operative
      management of common fractures, ligamentous sprains and
      muscular strains, and acute arthritis.
      .
7.    PG-1 - Familiarity with basic pathophysiology, clinical        DPC, FS, CC, IL,
                                                                                        AE
      manifestations, diagnosis and management of common             EMC
      otolaryngological emergencies, including epistaxis, acute
      pharyngitis, acute sinusitis, and obstruction of the upper
      airway.
      .
8.
      PG-1 - Familiarity with basic clinical manifestations,                            AE
                                                                     DPC, FS, CC, IL,
      diagnosis and management of common psychiatric
                                                                     EMC
      emergencies, including attempted suicide, acute psychosis
      and anxiety states.


9.                                                                   DPC, FS, CC, IL,
      Familiarity with recognition and treatment of non-emergent                        AE
                                                                     EMC, LL
      conditions frequently seen in emergency rooms, including
      allergic reactions, dermatitis and minor burns.
10.                                                                  DPC, FS, CC, IL,
      Recognition of signs of domestic violence, elderly abuse
                                                                     LL                 AE
      and other social issues which result in visits to the
      emergency room.
11.   Plan how to access and follow the Harris County Hospital                          AE
                                                                     FS
      District Disaster plan, in case of chemical, biological or
      nuclear emergency.
12.   PG-1 - Familiarity with indications for performance and
                                                                     DPC, FS, CC, IL,   AE
      basic interpretation of standard laboratory tests, including
                                                                     EMC
      blood counts, coagulation studies, blood chemistry tests,
      urinalysis, drug screens, body fluid analyses, and
      microbiologic tests.



                                                 61
 13.    Understanding the appropriate use of ultrasound, computed
                                                                       DPC, FS, CC,
        tomography and magnetic resonance imaging in emergency                            AE
                                                                       EMC
        diagnosis.
 14.    PG-1 - Basic familiarity with indications for performance      DPC, FS, CC, IL,
        and interpretation of imaging studies, including chest         EMC                AE
        X-ray, abdominal series, abdominal CT scan and CT scan
        of head.


C. Interpersonal Skills and Communication

                                                                       Learning           Evaluation
        Principal Educational Goals
                                                                       Activities         Methods
 1.     Communicate effectively with patients and families in a
                                                                       DPC, FS, PC, LL    AE, TYPD
        stressful Emergency Room environment.
 2.     Communicate effectively with physician colleagues in the
        ER & members of other health care professions to assure        DPC, FS, PC, LL    AE, TYPD
        timely, comprehensive patient care.
 3.     Communicate effectively with consulting residents and
        attendings from specialty services whose assistance is
                                                                       DPC, FS,PC, LL     AE, TYPD
        needed in the evaluation or management of patients in the
        ER.
 4.     Communicate effectively with colleagues when signing out
                                                                       DPC, FS, PC, LL    AE, TYPD
        patients.


D. Professionalism

                                                                       Learning           Evaluation
        Principal Educational Goals
                                                                       Activities         Methods
 1.     Interact professionally toward towards patients, families,
                                                                       DPC, FS, PC, LL    AE, TYPD
        colleagues, and all members of the health care team
 2.                                                                    DPC, PC,
        Appreciation of the social context of illness.                                    AE, TYPD
                                                                       FS

E.Practice-Based Learning and Improvement

                                                                       Learning           Evaluation
        Principal Educational Goals
                                                                       Activities         Methods
 1.     Identify and acknowledge gaps in personal knowledge and        DPC, FS, DO
                                                                                          AE
        skills in the care of patients with medical emergencies.       H&P
 2.                                                                    DPC, FS, EMC,
        Develop real-time strategies for filling knowledge gaps that
                                                                       NC                 AE
        will benefit patients with medical emergencies.
 3.     Commitment to professional scholarship, including                                 AE
        systematic and critical perusal of relevant print and          DPC, IL, NC,
        electronic literature, with emphases on integration of basic   SS,EMC
        science with clinical medicine, and evaluation of


                                                   62
        information in light of the principles of evidence-based
        medicine

F. Systems-Based Practice

                                                                       Learning           Evaluation
        Principal Educational Goals
                                                                       Activities         Methods
 1.     Understand and utilize the multidisciplinary resources
        necessary to care optimally for patients in the Emergency      DPC, FS            AE
        Room.
 2.     Collaborate with other members of the health care team to
        assure comprehensive care for patients in the Emergency        DPC, FS,PC, LL     AE
        Room.
 3.     Facilitate the safe and timely transfer of admitted patients
        from the Emergency Room to the appropriate inpatient           DPC, FS, PC,LL     AE
        setting.
 4.     Use evidence-based, cost-conscious strategies in the care of   DPC, FS, IL, CC,
                                                                                          AE
        patients with medical emergencies.                             NC, EMC
 5.     Effective collaboration with other members of the health                          AE
        care team, including residents at all levels, nurses,          DPC, FS, PC, LL
        emergency medical personnel, and social worker.




                                                  63
                                  General Surgery LBJ Hospital

Transitional year residents assigned to the General Surgery LBJ Hospital rotation work on a
team consisting of one General Surgery faculty member, one PGY5 surgery resident (the team
leader), one PGY3 surgery resident, one PGY2 surgery resident and three third year medical
students for one month. The transitional year resident is supervised by the senior residents
(PGY2, PGY3, and PGY5) and attending. During this rotation residents will gain knowledge in
basic assessment and overall management of surgical patients presenting to a community
hospital both in the in-patient and out-patient setting. In addition to caring for in-patients the TY
resident has two and one-half days of clinic (General, Breast and Colorectal) and also sees
patients in the emergency department. The Transitional Year resident will have an opportunity to
perform minor procedures and assist in the OR. Residents are required to attend all conferences
i.e. Morning Report, Grand Rounds, M&M, Multidisciplinary, Breast Conference, Multidisciplinary
GI Conference and Teaching Conference.

Call is one out of every five or six nights. The 80 hour work week is mandated.

Residents will gain knowledge and demonstrate understanding in the following areas:



      Legend for Learning Activities
      AR-Attending Rounds                              CC – Core Curriculum
      DPC – Direct Patient Care                 DSP – Directly Supervised Procedures
      EBM – Evidence Based Medicine             FS – Faculty Supervision
      GR – Grand Rounds                         MM- Mortality and morbidity
      conference
      LL – Lunch & Learn                            MR-Morning report
      BMC- Breast Multi-disciplinary conference
      GIMC-GI Multidisciplinary Conference


      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations       DSP – Directly Supervised Procedures
      MR – Morning Report                     PDR – Program Director’s Review
      (quarterly)
      PR – Peer Review                 TYPD – Transitional Year Program Director


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  64
     A. Patient Care
            Principal Education Goals                      Learning        Evaluation
                                                           Activities      Methods
       1.   Surgical Oncology
               a. The resident should be able to           DPC, AR         AE
                   accurately perform a complete
                   history and physical examination on
                   patients with cancer
               b. The resident should be able to           DSP, AR, DPC    AE, DSP
                   correctly manage colostomies and
                   ileostomies
               c. The resident should be able to           DSP, AR, DPC    AE, DSP
                   correctly close wounds following
                   major resection
       2    Breast
               a. The resident should be able to a         DPC, AR, BMC,   AE
                  history to evaluate breast patients to   MR
                  include pertinent risk factors,
                  previous history of breast problems,
                  current breast symptoms
               b. The resident should be able to           DPC, AR, BMC,   AE
                  perform a breast examination ,           MR
                  including recognition of the range of
                  variation in the normal breast
               c. The resident should be able to           DPC, AR, BMC,   AE
                  accurately identify common lesions       MR
                  such as fibroadenomas, cysts,
                  mastitis, and cancer
               d. The resident should be able to           DPC, AR         AE
                  correctly educate patients to
                  perform breast self-examination
       3.   Endocrine Surgery
              a. The resident should be able to            DPC, AR         AE
                 accurately perform a complete
                 history and physical examination on
                 patients
              b. The resident should be able to            DPC, AR, MR,    AE
                 correctly manage the pre-and post-        MM, GR
                 operative care of patients with
                 endocrine disease, under
                 supervision
            Abdominal Surgery
4.
                                                           AR, DPC         AE
               a. The resident should be able to

                                              65
                  accurately perform, record, and
                  report complete patient evaluation
                  and assessment
               b. The resident should be able to         AR, DPC, MR    AE
                  correctly evaluate and diagnose the
                  acute abdomen
               c. The resident should be able to         AR, DPC, MR,   AE
                  correctly co-ordinate pre-and post-    MM, GR
                  operative care for the patient with
                  the acute abdomen
  5.       Alimentary Tract
               a. The resident should be able to         AR, DPC,      AE
                  correctly evaluate emergency           NR,GIMC,MM,GR
                  department or clinic patients who
                  present with problems referable to
                  the GI tract
               b. The resident should be able to         DPC, DSP       AE
                  correctly serve as assistant to the
                  primary surgeon during operations
                  of the esophagus, stomach, small
                  intestine, colon, and anorectum
               c. The resident should be able to         DPC, AR, MR,   AE
                  accurately evaluate and correctly      GR
                  manage nutritional needs (enteral
                  and parenteral) of surgical patients
                  until normal GI function returns




B. Medical Knowledge
                     Principal Education Goals           Learning       Evaluation
                                                         Activities     Methods
       1             Surgical Oncology
           .
               a.  The resident should be able to        AR, DPC, GR    AE
                  accurately discuss frequency/death
                  rates of the top five benign and
                  malignant neoplasms in men,
                  women, and children in the United
                  States.
               b. The resident should be able to         AR, DPC,       AE
                  accurately describe trends of
                  increasing decreasing, and high
                  incidence for certain solid
                  neoplasms.
               c. The resident should be able to         AR, DPC        AE

                                             66
     correctly explain the implications of
     the heterogeneous cellular makeup
     of most solid neoplasms with
     reference to clinical behavior and
     response to adjuvant treatment.
d.    The resident should be able to          AR, DPC   AE
     accurately discuss the mechanisms
     of cellular apoptosis and the
     potential feasibility for therapeutic
     applications.
e.    The resident should be able to          AR, DPC   AE
     correctly identify genetic factors
     associated with neoplastic disease
     in regard to known proto-oncogenes.
f.    The resident should be able to          AR, DPC   AE
     accurately define current theories of
     carcinogenesis.
g.    The resident should be able to          AR, DPC   AE
     correctly summarize the tenets of
     tumor biology, including the
     biochemical events of invasion and
     metastasis; describe the natural
     history of these lesions.
h.    The resident should be able to          AR, DPC   AE
     accurately identify and differentiate
     between the diagnostic features of
     benign versus malignant neoplasms
     (gross and microscopic).
i.    The resident should be able to          AR, DPC   AE
     correctly predict patterns of
     presentation of malignant
     neoplasms.
j.    The resident should be able to          AR, DPC   AE
     accurately describe the
     characteristics of the various staging
     systems and explain their use in
     evaluating malignant neoplasms.
k.    The resident should be able to          AR, DPC   AE
     correctly outline the appropriate
     usage of tumor markers, tumor
     excretory metabolites, and
     diagnostic cytologic techniques.
l.    The resident should be able to          AR, DPC   AE
     accurately describe the principles of
     surgical technique for operative
     procedures designed for cure of
     malignant diseases and their
     application to endoscopic operative

                                67
   techniques.
m. The resident should be able to          AR, DPC           AE
   correctly summarize the nutritional
   requirements for cancer patients,
   and describe how they differ from
   those recommended for a healthy
   patient.
n. The resident should be able to          AR, DPC           AE
   accurately describe indications for
   curative versus palliative treatment,
   and formulate therapeutic plans for
   each approach.
o. The resident should be able to          AR, DPC           AE
   summarize current techniques of
   genetic screening for cancer.
p. The resident should be able to          AR, DPC           AE
   accurately describe the biologic
   rationale mechanisms, and current
   status of gene therapy for
   malignancy.
q. The resident should be able to          AR, DPC           AE
   correctly describe the enzymatic
   determinants of prognosis for
   epithelial derived cancers and their
   biologic sources.
r. The resident should be able to
   accurately discuss the economic and
   psychosocial issues associated with
   the malignant disease, and analyze
   how they affect the management of
   patients with cancer, including:
 1. Ethics of cancer management            AR, DPC, MR       AE
 2. Rehabilitation                         AR, DPC, MR       AE
 3. Home care resources                    AR, DPC, MR       AE
 4. Patient support groups                 AR, DPC, MR       AE
 5. Family support groups                  AR,DPC, MR        AE
 6. Enterostomal therapy                   AR, DPC, MR       AE
 7. Cost containment                       AR, DPC, MR, GR   AE
 8. Pre-admission procedures and           AR, DPC           AE
    authorization
 9. Special problems of the elderly        AR, DPC, MR, GR   AE
 10. Tumor registry data                   AR, BMC, GIMC,    AE
                                           MM


                              68
2             Breast Surgery
    .
        a. The resident should be able to          AR, DPC, BMC,   AE
           accurately describe the anatomy of      MR
           the breast.
        b. The resident should be able to          AR, DPC, BMC,   AE
           correctly explain the hormonal          MR
           regulation of the breast.
        c. The resident should be able to          AR, MR, BMC,    AE
           correctly summarize the incidence,      DPC
           epidemiology, and risk factors
           associated with breast cancer.
        d. The resident should be able to
           correctly distinguish between these
           common entities in the differential
           diagnosis of breast masses:
        1. Fibroadenomas                           AR, MR, BMC,    AE
                                                   DPC
        2. Fibrocystic disease                     AR, MR, BMC,    AE
                                                   DPC
        3. Cysts                                   AR, MR, BMC,    AE
                                                   DPC
        4. Fat necrosis                            AR, MR, BMC,    AE
                                                   DPC
        5. Abscesses                               AR, MR, BMC,    AE
                                                   DPC
        6. Cancer                                  AR, MR, BMC,    AE
                                                   DPC, GR
        e. The resident should be able to          BMC, AR, DPC,   AE
           accurately explain the general          MR
           indications, uses and limitations of
           mammography. Define the
           important and impact of screening
           mammography.
        f. The resident should be able to
           correctly describe the principles and
           historic context of the basic options
           available for the treatment of breast
           cancer such as:
        1. Radical mastectomy                      DPC, AR, MM,    AE
                                                   GR, BMC, MR
        2. Modified mastectomy                     DPC, AR, MM,    AE
                                                   GR, BMC, MR

                                      69
3. Lumpectomy and axillary dissection        DPC, AR, MM,   AE
                                             GR, BMC, MR
g. The resident should be able to            DPC, AR, MM,   AE
   accurately outline the genetic and        GR, BMC, MR
   environmental factors associated
   with carcinoma of the breast.
h. The resident should be able to            DPC, AR, MM,   AE
   correctly describe the following          GR, BMC, MR
   pathological types of breast cancer,
   including the biology, natural history
   and prognosis of each:
1. Infiltrating ductal carcinoma             DPC, AR, MM,   AE
                                             GR, BMC, MR
2. Ductal carcinoma in situ (DCIS)           DPC, AR, MM,   AE
                                             GR, BMC, MR
3. Infiltrating lobular carcinoma            DPC, AR, MM,   AE
                                             GR, BMC, MR
4. Lobular carcinoma in situ                 DPC, AR, MM,   AE
                                             GR, BMC, MR
i. The resident should be able to
   accurately describe the
   presentation, natural history,
   pathology, and treatment of the
   following benign breast diseases:
1. Lactational breast abscess                DPC, AR, MR    AE
2. Chronic recurring subareolar              DPC, AR, MR    AE
   abscess
3. Intraductal papilloma                     DPC, AR, MR    AE
4. Atypical epithelial hyperplasia           DPC, AR, MR    AE
5. Fibroadenoma                              DPC, AR, MR    AE
j. The resident should be able to            AR, DPC, MR    AE
   correctly explain the steps in clinical
   decision tree that are involved in
   the work-up of a breast mass.
k. The resident should be able to            AR, DPC, MR,   AE
   correctly explain the steps in the        MM, BMC
   clinical decision tree that are
   involved in the work-up of a breast
   mass.
l. The resident should be able to            AR, DPC, MR,   AE
   correctly explain the mechanics and       BMC
   potential value of the stereotactic
   needle biopsy.

                               70
        m. The resident should be able to          AR, DPC, MR,      AE
           accurately outline the diagnostic       BMC
           work-up and the differential
           diagnosis of various forms of nipple
           discharge.
        n. The resident should be able to          AR, DPC, MR,      AE
           correctly explain the use of tumor,     BMC
           nodes, and metastases (TNM)
           staging in the treatment of breast
           cancer.
        o. The resident should be able to          AR, DPC, MR,      AE
           accurately summarize the rationale      BMC
           for using a team approach to
           facilitate the complex discussions
           and explanation of options for the
           newly diagnosed breast cancer
           patient prior to definitive treatment
           (e.g., team of oncologist, surgeon,
           plastic surgeon, and radiation
           therapist).
        p. The resident should be able to          AR, DPC, MR,      AE
           correctly explain the role of           BMC
           reduction and augmentation
           mammoplasty.
3             Endocrine Surgery
    .
        a. Be able to accurately describe the
           normal anatomy, histology,
           physiology, and pertinent
           biochemistry of the following
           organs:
        1. Thyroid gland                           AR, DPC, MR, CC   AE
        2. Parathyroid gland                       AR, DPC, MR, CC   AE
        3. Hypothalamus                            AR, DPC, MR, CC   AE
        4. Pituitary gland                         AR, DPC, MR, CC   AE
        5. Endocrine pancreas                      AR, DPC, MR, CC   AE
        6. Adrenal glands                          AR, DPC, MR, CC   AE
        7. Gastrointestinal tract as an            AR, DPC, MR, CC   AE
           endocrine organ
        8. Gonads as endocrine organs              AR, DPC, MR, CC   AE
        b. Be able to correctly describe the
           secretion and the control thereof of
           the following:


                                      71
1. Thyroxine and thyroid stimulating       AR, DPC, MR, CC   AE
   hormone
2. Parathyroid hormone                     AR, DPC, MR, CC   AE
3. Adrenocorticotropic hormone             AR, DPC, MR, CC   AE
   (ACTH)/cortisol
4. Insulin                                 AR, DPC, MR, CC   AE
5. Glucagon                                AR, DPC, MR, CC   AE
6. Catecholamine                           AR, DPC, MR, CC   AE
a. Epinephrine                             AR, DPC, MR, CC   AE
b. Norepinephrine                          AR, DPC, MR, CC   AE
c. Dopamine                                AR, DPC, MR, CC   AE
7. Gastrin                                 AR, DPC, MR, CC   AE
8. Secretin                                AR, DPC, MR, CC   AE
9. Cholecystokinin                         AR, DPC, MR, CC   AE
10. Serotonin/histamine                    AR, DPC, MR, CC   AE
11. Estrogen/progesterone/testosteron      AR, DPC, MR, CC   AE
    e (and their releasing factors)
12. Oxytocin/vasopressin                   AR, DPC, MR, CC   AE
13. Growth hormone                         AR, DPC, MR, CC   AE
14. Melanocyte stimulating hormone         AR, DPC, MR, CC   AE
15. Prolactin                              AR, DPC, MR, CC   AE
16. Motilin/gastric inhibitory             AR, DPC, MR, CC   AE
    peptide/enteroglucagon/vasoactive
    intestinal peptide
17. Somatostatin                           AR, DPC, MR, CC   AE
c. Be able to correctly summarize the
   following aspects of endocrine
   pathology:
1. Criteria for the diagnosis of           AR, GR, DPC, MR, AE
   malignancy                              CC
2. Chromosomal abnormalities as a          AR, GR, DPC, MR, AE
   screening/diagnostic tool               CC
3. The unique characteristics about        AR, GR, DPC, MR, AE
   the clinical epidemiology of patients   CC
   with sporadic versus familiar
   disease
d. Be able to accurately define and        AR, GR, DPC, MR, AE
   differentiate multiple endocrine        CC

                              72
           neoplasia (MEN) type I, MEN II and
           familial non-MEN syndromes
        e. Be able to correctly explain the       AR, GR, DPC, MR, AE
           integrated concept of clinical         CC
           neuroendocrinology, the cells and
           organs of the amine precursor
           uptake decarboxylase (APUD)
           system and the knowledge of
           clinical endocrine syndromes.
        f. Be able to correctly list the
           differential diagnoses of:
        1. Hypercalcemia                          AR, DPC, MR       AE
        2. Hypoglycemia                           AR, DPC, MR       AE
        3. Hypergastrinemia                       AR, DPC, MR       AE
        4. Elevated serum thyroxine level         AR, DPC, MR       AE
        5. Decreased sensitive thyroid            AR, DPC, MR       AE
           stimulating hormone (TSH) level
        6. Elevated ACTH levels                   AR, DPC, MR       AE
4        Abdominal Surgery
    .
        a. The resident should correctly          DSP, AR, CC, MR   AE
           describe the embryological
           development of the peritoneal cavity
           and the positioning of the
           abdominal viscera
        b. The resident should be able to         AR, CC, MR        AE
           differentiate between incarceration
           and strangulation
        c. The resident should be able to         AR, CC, MR, DSP   AE, DSP
           correctly define a Richter’s hernia
           and describe its clinical
           presentation
        d. The resident should be able to         AR, CC, MR, DSP   AE, DSP
           name the hernia types that are most
           common in elderly patients, and
           explain how they become
           problematic
        e. The resident should be able to         AR, MR, CC, GR    AE
           correctly describe the anatomy of
           the omentum and its role in
           responding to inflammatory
           processes
        f. The resident should be able to         DPC, AR, CC       AE
           assess the following signs: referred
           pain, guarding, rebound

                                     73
           tenderness, and rigidity
        g. The resident should be able to              DPC, AR, CC, GR,   AE
           specify history and physical                MR, MM
           diagnostic findings for acute
           appendicitis, ureteral colic, bowel
           obstruction, diffuse peritonitis,
           perforated ulcer and biliary colic
        h. The resident should be able to              DPC, AR, CC,       AE
           accurately explain the mechanism            MM, MR
           of referred pain in: ruptured spleen,
           renal colic, biliary colic, pancreatitis,
           basilar pneumonia, and inguinal
           hernia
        i. The resident should be able to              DPC, AR, CC,       AE
           correctly delineate the                     MM, MR
           pathophysiology of the following
           causes of paralytic ileus:
           postoperative electrolyte imbalance,
           retroperitoneal pathology, trauma,
           and extraperitoneal disease (CNS,
           lung)
        j. The resident should be able to              DPC, AR, CC,       AE
           describe accurately the risk factors        MM, MR
           for abdominal wound infection, and
           the contributing factors for
           abdominal wound dehiscence and
           evisceration


C.Interpersonal Skills and Communication

      Principal Education Goals                           Learning        Evaluation
                                                          Activities      Methods
  1. Clearly, accurately and succinctly present           AR              AE
     pertinent information to faculty regarding
     patients new to the service including newly
     admitted patients and patients for whom the
     service has been consulted.
  2. Clearly, accurately and respectfully communicate     AR,LL           AE
     with nurses and other hospital employees.
  3. Clearly, accurately and respectfully communicate     AR,LL           AE
     with referring and consulting physicians,
     including fellow residents.
  4. Clearly, accurately and respectfully communicate     AR, LL          AE
     with patients and appropriate members of their
     families identified disease processes (including
     complications), the expected courses, operative

                                         74
         findings and operative procedures.
    5.   Maintain clear, concise, accurate and timely        AR           AE
         medical records including (but not limited to)
         admission history and physical examination
         notes, consultation notes,progress notes, orders,
         operative notes and discharge summaries.

D. Professionalism

         Principal Education Goals                           Learning     Evaluation
                                                             Activities   Methods
    1. Be honest with all individuals at all times in        LL, AR       AE, TYPD
       conveying issues of patient care.
    2. Place the needs of the patient above the needs or     LL, AR       AE, TYPD
       desires of self.
    3. Maintain high ethical behavior in all professional    LL, AR       AE, TYPD
       activities.
    4. Demonstrate commitment to continuity of care          LL, AR       AE, TYPD
       through carrying out her/his own personal
       responsibilities or through assuring that those
       responsibilities are fully and accurately conveyed
       to others acting in her/his stead.
    5. At any time while engaged in patient care, be         LL           AE, TYPD
       properly and professionally groomed.
    7. Demonstrate sensitivity to issues of age, race,       LL, AR       AE, TYPD
       gender and religion with patients, families and all
       members of the health care team.
    8. At all times treat patients, families and all         LL, AR       AE, TYPD
       members of the health care team with respect.
    9. Reliably be present in pre-arranged places and at     LL           AE, TYPD
       pre-arranged times except when the resident is
       actively engaged in the treatment of a surgical or
       medical emergency. Under such circumstances,
       the resident should provide timely notification to
       the appropriate individual(s) of her/his inability
       to engage in the pre-arranged activity.




E. Practice-Based Learning and Improvement

         Principal Education Goals                           Learning     Evaluation
                                                             Activities   Methods
    1. Maintain a detailed log of procedures and
       operative cases in which (s)he participates


                                            75
         including:
         a.      Diagnosis                                     DSP, AP      AE, TYPD
         b.        Procedure performed                         DSP, AP      AE, TYPD
         c.       Postoperative course of the patient          DSP, AP      AE, TYPD
              including any complications sustained
              and an analysis of the origins of each
              complication.
    2.              Maintain a portfolio of rotation related   AP           AE, TYPD
                       literature searches.
    3.              Maintain a portfolio of rotation related   AP           AE, TYPD
                       formal presentations including
                       presentation of complications
                       (Morbidity and Mortality
                       Conference).




F. Systems Based Practice

         Principal Education Goals                             Learning     Evaluation
                                                               Activities   Methods
    1. Appropriately utilize in a timely and cost efficient
       manor ancillary services including:
          a. Social work                                       AS, AR       AE
              b. Discharge planning                            AS, AR       AE
              c. Physical therapy                              AS, AR       AE
              d. Occupational therapy                          AS, AR       AE
              e. Respiratory therapy                           AS, AR       AE
              f.   Nutrition services                          AS, AR       AE
              g. Pharmacists                                   AS, AR       AE
             h. Physician extenders including                  AS, AR       AE
                  physicians’ assistants and nurse
                  practitioners
    2.   Appropriately utilize consultations from other        AR           AE
         surgical and medical specialties in a timely and
         cost efficient manor to facilitate and enhance
         patient care.
    3.   Summarize the financial costs, the risks and the      AR           AE
         benefits of all proposed diagnostic studies and
         therapeutic interventions.
    4.   Offer sound justification for all diagnostic tests    AR           AE
         (including laboratory studies) ordered by her/him.

                                             76
                            General Surgery Memorial Hermann Hospital

Transitional year residents assigned to the General Surgery Memorial Hermann
Hospital rotation are assigned to either the Dudrick (EGS) service or Moody service.
The Dudrick service is a surgical consult service staffed by many senior faculty in the
department of surgery with their expertise including complex GI, surgical oncology,
hepatobiliary, and endocrine surgery), as well as a complement of residents. The
Moody Service is an elective general surgery service with an emphasis on minimally
invasive surgery. This service is staffed by many senior faculty in the department of
surgery, as well as a complement of residents. The transitional year resident is
supervised by senior residents and the attending. During this rotation residents will gain
knowledge in basic assessment and overall management of surgical patients
presenting to a tertiary/quaternary teaching and referral hospital. The Transitional Year
resident will have an opportunity to perform minor procedures and assist in the OR
commensurate with their training and level of experience. Residents are required to
attend all conferences.

The 80 hour work week is mandated.

Residents will gain knowledge and demonstrate understanding in the following areas:

A. Surgical Oncology
    1. Demonstrate understanding of the biology, pathology, diagnosis, treatment, and
       prognosis of neoplastic diseases.
    2. Demonstrate proficiency in diagnosis, preparation, operative treatment, and total
       management of the cancer patient, including long-term follow-up care.
    3. Understand surgical options of curative and palliative care for cancer patients.
    4. Understand the network of community resources and their functions, available to patients at end of life.
B. Breast
    1. Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the breast.
    2. Demonstrate the ability to surgically manage diseases of the breast.
    3. Understand the advancements of minimally invasive and conservative breast surgeries.
C. Endocrine
    1. Demonstrate knowledge of endocrine anatomy and physiology, both normal and
       pathological.
    2. Demonstrate the ability to apply this knowledge to the surgical care of patients.
D. Abdomen
    1. Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases of
       the abdominal cavity and pelvis.

    2. 2. Demonstrate the ability to formulate and implement a diagnostic and treatment s of the
       abdomen and pelvis that are amenable to surgical intervention.

E. Alimentary Tract

    1. Demonstrate an understanding of the anatomy, physiology, and pathophysiology of the
       alimentary tract and digestive system.


                                                        77
    2. Demonstrate the ability to manage problems of the alimentary tract and digestive system
       that are amendable to surgical intervention.
F. Liver, Biliary Tract and Pancreas

    1. Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the liver,
       biliary tract, and pancreas.
    2. Demonstrate the ability to manage disease and injury of the liver, biliary tract, and
       pancreas amenable to surgical intervention.
G. Surgical Endoscopy

    1. Demonstrate knowledge of and the ability to use a variety of endoscopic instruments in
       the screening, diagnosis and treatment of various diseases.

H. Minimal Access Surgery

    1. Demonstrate an understanding of the applications and risks of minimal access surgery
       (MAS).
    2. Demonstrate an understand of the technical and physiologic principles of minimal access
       surgical techniques.
    3. Develop specific technical skills and demonstrate proficiency in performance of basic
       laparoscopy, laparoscopic cholecystectomy, and other minimal access procedures.
    4. Synthesize the principles of minimal access surgery into a practice philosophy conducive
       to the development and evaluation of future surgical techniques.

      Legend for Learning Activities
      AR-Attending Rounds                              CC – Core Curriculum
      DPC – Direct Patient Care                        DSP – Directly Supervised Procedures
      EBM – Evidence Based Medicine                    FS – Faculty Supervision
      GR – Grand Rounds                                LL – Lunch & Learn
      MR-Morning report
      BMC- Breast Multi-disciplinary conference
      GIMC-GI Multidisciplinary Conference
      MM- Mortality and morbidity conference

      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations       DSP – Directly Supervised Procedures
      MR – Morning Report              PDR – Program Director’s Review (quarterly)
      PR – Peer Review                 TYPD – Transitional Year Program Director


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.


    A. Patient Care

                                                  78
                   Principal Education Goals                    Learning        Evaluation
                                                                Activities      Methods
1.                 Surgical Oncology
             A. The resident should be able to accurately       DPC, AR         AE
                perform a complete history and physical
                examination on patients with cancer
             B. The resident should be able to correctly        DSP, AR, DPC    AE, DSP
                manage colostomies and ileostomies
             C. The resident should be able to correctly        DSP, AR, DPC    AE, DSP
                close wounds following major resection
2                  Breast
             A. The resident should be able to a history to     DPC, AR, BMC,   AE
                evaluate breast patients to include pertinent   MR
                risk factors, previous history of breast
                problems, current breast symptoms
             B. The resident should be able to perform a        DPC, AR, BMC,   AE
                breast examination , including recognition      MR
                of the range of variation in the normal
                breast
             C. The resident should be able to accurately       DPC, AR, BMC,   AE
                identify common lesions such as                 MR
                fibroadenomas, cysts, mastitis, and cancer
             D. The resident should be able to correctly        DPC, AR         AE
                educate patients to perform breast self-
                examination
3.                 Endocrine Surgery
             A. The resident should be able to accurately       DPC, AR         AE
                perform a complete history and physical
                examination on patients
             B. The resident should be able to correctly        DPC, AR, MR,    AE
                manage the pre-and post-operative care of       MM, GR
                patients with endocrine disease, under
                supervision
     4.   Abdominal Surgery
                                                                AR, DPC         AE
             A. The resident should be able to accurately
                perform, record, and report complete
                patient evaluation and assessment
             B. The resident should be able to correctly        AR, DPC, MR     AE
                evaluate and diagnose the acute abdomen

             C. The resident should be able to correctly co-    AR, DPC, MR,    AE
                ordinate pre-and post-operative care for        MM, GR
                the patient with the acute abdomen
5.                Alimentary Tract


                                           79
         A. The resident should be able to correctly        AR, DPC,          AE
            evaluate emergency department or clinic         NR,GIMC,MM,G
            patients who present with problems              R
            referable to the GI tract
         B. The resident should be able to correctly        DPC, DSP          AE
            serve as assistant to the primary surgeon
            during operations of the esophagus,
            stomach, small intestine, colon, and
            anorectum
         C. The resident should be able to accurately       DPC, AR, MR, GR AE
            evaluate and correctly manage nutritional
            needs (enteral and parenteral) of surgical
            patients until normal GI function returns




C. Medical Knowledge
                 Principal Education Goals                  Learning     Evaluation
                                                            Activities   Methods
    1.           Surgical Oncology
           A. The resident should be able to accurately     AR, DPC,     AE
              discuss frequency/death rates of the top      GR
              five benign and malignant neoplasms in
              men, women, and children in the United
              States.
           B. The resident should be able to accurately     AR, DPC,     AE
              describe trends of increasing decreasing,
              and high incidence for certain solid
              neoplasms.
           C. The resident should be able to correctly      AR, DPC      AE
              explain the implications of the
              heterogeneous cellular makeup of most
              solid neoplasms with reference to clinical
              behavior and response to adjuvant
              treatment.
           D. The resident should be able to accurately     AR, DPC      AE
              discuss the mechanisms of cellular
              apoptosis and the potential feasibility for
              therapeutic applications.
           E. The resident should be able to correctly      AR, DPC      AE
              identify genetic factors associated with
              neoplastic disease in regard to known
              proto-oncogenes.
           F. The resident should be able to accurately     AR, DPC      AE
              define current theories of carcinogenesis.
           G. The resident should be able to correctly      AR, DPC      AE
              summarize the tenets of tumor biology,

                                       80
     including the biochemical events of
     invasion and metastasis; describe the
     natural history of these lesions.
H.   The resident should be able to accurately     AR, DPC   AE
     identify and differentiate between the
     diagnostic features of benign versus
     malignant neoplasms (gross and
     microscopic).
I.   The resident should be able to correctly      AR, DPC   AE
     predict patterns of presentation of
     malignant neoplasms.
J.   The resident should be able to accurately     AR, DPC   AE
     describe the characteristics of the various
     staging systems and explain their use in
     evaluating malignant neoplasms.
K.   The resident should be able to correctly      AR, DPC   AE
     outline the appropriate usage of tumor
     markers, tumor excretory metabolites, and
     diagnostic cytologic techniques.
L.   The resident should be able to accurately     AR, DPC   AE
     describe the principles of surgical
     technique for operative procedures
     designed for cure of malignant diseases
     and their application to endoscopic
     operative techniques.
M.   The resident should be able to correctly      AR, DPC   AE
     summarize the nutritional requirements for
     cancer patients, and describe how they
     differ from those recommended for a
     healthy patient.
N.   The resident should be able to accurately     AR, DPC   AE
     describe indications for curative versus
     palliative treatment, and formulate
     therapeutic plans for each approach.
O.   The resident should be able to summarize      AR, DPC   AE
     current techniques of genetic screening
     for cancer.
P.   The resident should be able to accurately     AR, DPC   AE
     describe the biologic rationale
     mechanisms, and current status of gene
     therapy for malignancy.
Q.   The resident should be able to correctly      AR, DPC   AE
     describe the enzymatic determinants of
     prognosis for epithelial derived cancers
     and their biologic sources.
R.   The resident should be able to accurately
     discuss the economic and psychosocial
     issues associated with the malignant
     disease, and analyze how they affect the

                             81
         management of patients with cancer,
         including:
     11. Ethics of cancer management                AR, DPC,   AE
                                                    MR
     12. Rehabilitation                             AR, DPC,   AE
                                                    MR
     13. Home care resources                        AR, DPC,   AE
                                                    MR
     14. Patient support groups                     AR, DPC,   AE
                                                    MR
     15. Family support groups                      AR, DPC,   AE
                                                    MR
     16. Enterostomal therapy                       AR, DPC,   AE
                                                    MR
     17. Cost containment                           AR, DPC,   AE
                                                    MR, GR
     18. Pre-admission procedures and               AR, DPC    AE
         authorization
     19. Special problems of the elderly            AR, DPC,   AE
                                                    MR, GR
     20. Tumor registry data                        AR, BMC,   AE
                                                    GIMC, MM
2.         Breast Surgery
     q. The resident should be able to accurately   AR, DPC,   AE
        describe the anatomy of the breast.         BMC, MR
     r. The resident should be able to correctly    AR, DPC,   AE
        explain the hormonal regulation of the      BMC, MR
        breast.
     s. The resident should be able to correctly    AR, MR,    AE
        summarize the incidence, epidemiology,      BMC, DPC
        and risk factors associated with breast
        cancer.
     t. The resident should be able to correctly
        distinguish between these common
        entities in the differential diagnosis of
        breast masses:
     7. Fibroadenomas                               AR, MR,    AE
                                                    BMC, DPC
     8. Fibrocystic disease                         AR, MR,    AE
                                                    BMC, DPC


                                  82
9. Cysts                                          AR, MR,     AE
                                                  BMC, DPC
10. Fat necrosis                                  AR, MR,     AE
                                                  BMC, DPC
11. Abscesses                                     AR, MR,     AE
                                                  BMC, DPC
12. Cancer                                        AR,MR,      AE
                                                  BMC, DPC,
                                                  GR
u. The resident should be able to accurately      BMC, AR,    AE
   explain the general indications, uses and      DPC, MR
   limitations of mammography. Define the
   important and impact of screening
   mammography.
v. The resident should be able to correctly
   describe the principles and historic context
   of the basic options available for the
   treatment of breast cancer such as:
4. Radical mastectomy                             DPC, AR,    AE
                                                  MM, GR,
                                                  BMC, MR
5. Modified mastectomy                            DPC, AR,    AE
                                                  MM, GR,
                                                  BMC, MR
6. Lumpectomy and axillary dissection             DPC, AR,    AE
                                                  MM, GR,
                                                  BMC, MR
w. The resident should be able to accurately      DPC, AR,    AE
   outline the genetic and environmental          MM, GR,
   factors associated with carcinoma of the       BMC, MR
   breast.
x. The resident should be able to correctly       DPC, AR,    AE
   describe the following pathological types      MM, GR,
   of breast cancer, including the biology,       BMC, MR
   natural history and prognosis of each:
5. Infiltrating ductal carcinoma                  DPC, AR,    AE
                                                  MM, GR,
                                                  BMC, MR
6. Ductal carcinoma in situ (DCIS)                DPC, AR,    AE
                                                  MM, GR,
                                                  BMC, MR
7. Infiltrating lobular carcinoma                 DPC, AR,    AE

                             83
                                                   MM, GR,
                                                   BMC, MR
8. Lobular carcinoma in situ                       DPC, AR,   AE
                                                   MM, GR,
                                                   BMC, MR
y. The resident should be able to accurately
   describe the presentation, natural history,
   pathology, and treatment of the following
   benign breast diseases:
6. Lactational breast abscess                      DPC, AR,   AE
                                                   MR
7. Chronic recurring subareolar abscess            DPC,AR,    AE
                                                   MR
8. Intraductal papilloma                           DPC, AR,   AE
                                                   MR
9. Atypical epithelial hyperplasia                 DPC, AR,   AE
                                                   MR
10. Fibroadenoma                                   DPC, AR,   AE
                                                   MR
z. The resident should be able to correctly        AR, DPC,   AE
    explain the steps in clinical decision tree    MR
    that are involved in the work-up of a breast
    mass.
aa. The resident should be able to correctly       AR, DPC,   AE
    explain the steps in the clinical decision     MR, MM,
    tree that are involved in the work-up of a     BMC
    breast mass.
bb. The resident should be able to correctly       AR,DPC,    AE
    explain the mechanics and potential value      MR, BMC
    of the stereotactic needle biopsy.
cc. The resident should be able to accurately      AR, DPC,   AE
    outline the diagnostic work-up and the         MR, BMC
    differential diagnosis of various forms of
    nipple discharge.
dd. The resident should be able to correctly       AR, DPC,   AE
    explain the use of tumor, nodes, and           MR, BMC
    metastases (TNM) staging in the
    treatment of breast cancer.
ee. The resident should be able to accurately      AR, DPC,   AE
    summarize the rationale for using a team       MR, BMC
    approach to facilitate the complex
    discussions and explanation of options for
    the newly diagnosed breast cancer patient
    prior to definitive treatment (e.g., team of

                             84
         oncologist, surgeon, plastic surgeon, and
         radiation therapist).
     ff. The resident should be able to correctly     AR, DPC,   AE
         explain the role of reduction and            MR, BMC
         augmentation mammoplasty.
3.         Endocrine Surgery
     g. Be able to accurately describe the normal
        anatomy, histology, physiology, and
        pertinent biochemistry of the following
        organs:
     9. Thyroid gland                                 AR, DPC,   AE
                                                      MR, CC
     10. Parathyroid gland                            AR, DPC,   AE
                                                      MR, CC
     11. Hypothalamus                                 AR, DPC,   AE
                                                      MR, CC
     12. Pituitary gland                              AR, DPC,   AE
                                                      MR, CC
     13. Endocrine pancreas                           AR, DPC,   AE
                                                      MR, CC
     14. Adrenal glands                               AR, DPC,   AE
                                                      MR, CC
     15. Gastrointestinal tract as an endocrine       AR, DPC,   AE
         organ                                        MR, CC
     16. Gonads as endocrine organs                   AR, DPC,   AE
                                                      MR, CC
     h. Be able to correctly describe the secretion
         and the control thereof of the following:
     18. Thyroxine and thyroid stimulating hormone    AR, DPC,   AE
                                                      MR, CC
     19. Parathyroid hormone                          AR, DPC,   AE
                                                      MR, CC
     20. Adrenocorticotropic hormone                  AR, DPC,   AE
         (ACTH)/cortisol                              MR, CC
     21. Insulin                                      AR, DPC,   AE
                                                      MR, CC
     22. Glucagon                                     AR, DPC,   AE
                                                      MR, CC
     23. Catecholamine                                AR, DPC,   AE
                                                      MR, CC
     d. Epinephrine                                   AR, DPC,   AE
                                                      MR, CC
     e. Norepinephrine                                AR, DPC,   AE
                                                      MR, CC


                                 85
f.   Dopamine                                    AR, DPC,   AE
                                                 MR, CC
24. Gastrin                                      AR, DPC,   AE
                                                 MR, CC
25. Secretin                                     AR, DPC,   AE
                                                 MR, CC
26. Cholecystokinin                              AR, DPC,   AE
                                                 MR, CC
27. Serotonin/histamine                          AR, DPC,   AE
                                                 MR, CC
28. Estrogen/progesterone/testosterone (and      AR, DPC,   AE
    their releasing factors)                     MR, CC
29. Oxytocin/vasopressin                         AR, DPC,   AE
                                                 MR, CC
30. Growth hormone                               AR, DPC,   AE
                                                 MR, CC
31. Melanocyte stimulating hormone               AR, DPC,   AE
                                                 MR, CC
32. Prolactin                                    AR, DPC,   AE
                                                 MR, CC
33. Motilin/gastric inhibitory                   AR, DPC,   AE
    peptide/enteroglucagon/vasoactive            MR, CC
    intestinal peptide
34. Somatostatin                                 AR, DPC,   AE
                                                 MR, CC
i. Be able to correctly summarize the
   following aspects of endocrine pathology:
4. Criteria for the diagnosis of malignancy      AR,GR,     AE
                                                 DPC, MR,
                                                 CC
5. Chromosomal abnormalities as a                AR, GR,    AE
   screening/diagnostic tool                     DPC, MR,
                                                 CC
6. The unique characteristics about the          AR, GR,    AE
   clinical epidemiology of patients with        DPC, MR,
   sporadic versus familiar disease              CC
j. Be able to accurately define and              AR, GR,    AE
   differentiate multiple endocrine neoplasia    DPC, MR,
   (MEN) type I, MEN II and familial non-        CC
   MEN syndromes
k. Be able to correctly explain the integrated   AR, GR,    AE
   concept of clinical neuroendocrinology,       DPC, MR,
   the cells and organs of the amine             CC
   precursor uptake decarboxylase (APUD)

                            86
        system and the knowledge of clinical
        endocrine syndromes.
     l. Be able to correctly list the differential
        diagnoses of:
     7. Hypercalcemia                                  AR,DPC,    AE
                                                       MR
     8. Hypoglycemia                                   AR, DPC,   AE
                                                       MR
     9. Hypergastrinemia                               AR, DPC,   AE
                                                       MR
     10. Elevated serum thyroxine level                AR,DPC,    AE
                                                       MR
     11. Decreased sensitive thyroid stimulating       AR, DPC,   AE
         hormone (TSH) level                           MR
     12. Elevated ACTH levels                          AR, DPC,   AE
                                                       MR
4.    Abdominal Surgery

     k. The resident should correctly describe the     DSP, AR,   AE
        embryological development of the               CC, MR
        peritoneal cavity and the positioning of the
        abdominal viscera
     l. The resident should be able to                 AR, CC, MR AE
        differentiate between incarceration and
        strangulation
     m. The resident should be able to correctly       AR, CC,    AE, DSP
        define a Richter’s hernia and describe its     MR, DSP
        clinical presentation
     n. The resident should be able to name the        AR, CC,    AE, DSP
        hernia types that are most common in           MR, DSP
        elderly patients, and explain how they
        become problematic
     o. The resident should be able to correctly       AR, MR,    AE
        describe the anatomy of the omentum and        CC, GR
        its role in responding to inflammatory
        processes
     p. The resident should be able to assess the      DPC, AR,   AE
        following signs: referred pain, guarding,      CC
        rebound tenderness, and rigidity
     q. The resident should be able to specify         DPC, AR,   AE
        history and physical diagnostic findings for   CC, GR,
        acute appendicitis, ureteral colic, bowel      MR, MM
        obstruction, diffuse peritonitis, perforated
        ulcer and biliary colic


                                   87
            r. The resident should be able to accurately         DPC, AR,    AE
               explain the mechanism of referred pain in:        CC, MM,
               ruptured spleen, renal colic, biliary colic,      MR
               pancreatitis, basilar pneumonia, and
               inguinal hernia
            s. The resident should be able to correctly          DPC, AR,    AE
               delineate the pathophysiology of the              CC, MM,
               following causes of paralytic ileus:              MR
               postoperative electrolyte imbalance,
               retroperitoneal pathology, trauma, and
               extraperitoneal disease (CNS, lung)
            t. The resident should be able to describe           DPC, AR,    AE
               accurately the risk factors for abdominal         CC, MM,
               wound infection, and the contributing             MR
               factors for abdominal wound dehiscence
               and evisceration

D. Interpersonal Skills and Communication

        Principal Education Goals                           Learning        Evaluation
                                                            Activities      Methods
    1. Clearly, accurately and succinctly present           AR              AE
       pertinent information to faculty regarding
       patients new to the service including newly
       admitted patients and patients for whom the
       service has been consulted.
    2. Clearly, accurately and respectfully                 AR,LL           AE
       communicate with nurses and other hospital
       employees.
    3. Clearly, accurately and respectfully                 AR,LL           AE
       communicate with referring and consulting
       physicians, including fellow residents.
    4. Clearly, accurately and respectfully                 AR, LL          AE
       communicate with patients and appropriate
       members of their families identified disease
       processes (including complications), the
       expected courses, operative findings and
       operative procedures.
    5. Maintain clear, concise, accurate and timely         AR              AE
       medical records including (but not limited to)
       admission history and physical examination
       notes, consultation notes, progress notes, orders,
       operative notes and discharge summaries.




                                           88
E. Professionalism

        Principal Education Goals                           Learning     Evaluation
                                                            Activities   Methods
    1. Be honest with all individuals at all times in       LL, AR       AE, TYPD
       conveying issues of patient care.
    2. Place the needs of the patient above the needs or    LL, AR       AE, TYPD
       desires of self.
    3. Maintain high ethical behavior in all                LL, AR       AE, TYPD
       professional activities.
    4. Demonstrate commitment to continuity of care         LL, AR       AE, TYPD
       through carrying out her/his own personal
       responsibilities or through assuring that those
       responsibilities are fully and accurately
       conveyed to others acting in her/his stead.
    5. At any time while engaged in patient care, be        LL           AE, TYPD
       properly and professionally groomed.
    7. Demonstrate sensitivity to issues of age, race,      LL, AR       AE, TYPD
       gender and religion with patients, families and
       all members of the health care team.
    8. At all times treat patients, families and all        LL, AR       AE, TYPD
       members of the health care team with respect.
    9. Reliably be present in pre-arranged places and at    LL           AE, TYPD
       pre-arranged times except when the resident is
       actively engaged in the treatment of a surgical or
       medical emergency. Under such circumstances,
       the resident should provide timely notification to
       the appropriate individual(s) of her/his inability
       to engage in the pre-arranged activity.



F. Practice-Based Learning and Improvement

        Principal Education Goals                           Learning     Evaluation
                                                            Activities   Methods
    1. Maintain a detailed log of procedures and
       operative cases in which (s)he participates
       including:
           A. Diagnosis                                     DSP, AP      AE, TYPD
            B. Procedure performed                          DSP, AP      AE, TYPD
            C. Postoperative course of the patient          DSP, AP      AE, TYPD
               including any complications sustained


                                           89
                  and an analysis of the origins of each
                  complication.
     2.   Maintain a portfolio of rotation related literature   AP           AE, TYPD
          searches.
     3.   Maintain a portfolio of rotation related formal       AP           AE, TYPD
          presentations including presentation of
          complications (Morbidity and Mortality
          Conference).


D. Systems Based Practice

          Principal Educatio Goals                              Learning     Evaluation
                                                                Activities   Methods
     1. Appropriately utilize in a timely and cost
        efficient manor ancillary services including:
            A. Social work                                      AS, AR       AE
              B. Discharge planning                             AS, AR       AE
              C. Physical therapy                               AS, AR       AE
              D. Occupational therapy                           AS, AR       AE
              E. Respiratory therapy                            AS, AR       AE
              F. Nutrition services                             AS, AR       AE
              G. Pharmacists                                    AS, AR       AE
              H. Physician extenders including                  AS, AR       AE
                   physicians’ assistants and nurse
                   practitioners
     2.   Appropriately utilize consultations from other        AR           AE
          surgical and medical specialties in a timely and
          cost efficient manor to facilitate and enhance
          patient care.
     3.   Summarize the financial costs, the risks and the      AR           AE
          benefits of all proposed diagnostic studies and
          therapeutic interventions.
     4.   Offer sound justification for all diagnostic tests    AR           AE
          (including laboratory studies) ordered by
          her/him.




                                              90
      Pediatric Surgery – Memorial Hermann Hospital, MD Anderson Cancer Center

        The Pediatric Surgery rotation is a one month rotation to which Transitional Year
        Residents are assigned. Residents assigned to the Memorial Hermann Hospital, MD
        Anderson Cancer Center Pediatric Surgery Rotation work on a team consisting of a
        fellow, two senior residents (either PGY 2 or PGY 3) and one to two interns (PGY1).
        Transitional Year residents will understand the unique anatomic, pathophysiologic, and
        genetic conditions that affect the fetus, the neonate and the child. They will learn the
        principles of stabilization, appropriate preoperative diagnosis, and preparation of the sick
        neonate and child; understand the anatomic and physiologic principles which guide
        successful operative repair of neonatal and pediatric diseases; learn principles of routine
        postoperative care and postoperative critical care management in the neonate and child;
        and understand how new techniques, such as fetal surgery, may offer alternatives for
        treatment of certain neonatal diseases.

        Call is every third or fourth night with supervision from the in-house resident and faculty.
        Adherence to the 80 hour work week is mandated.

      Legend for Learning Activities
      AR-Attending Rounds                CC – Core Curriculum
      DPC – Direct Patient Care          EBM – Evidence Based Medicine
      FS – Faculty Supervision           MR- Morning report
      GR – Grand Rounds
      LL – Lunch & Learn
      DSP – Directly Supervised Procedures



      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations       DSP – Directly Supervised Procedures
      MR – Morning Report              PDR – Program Director’s Review (quarterly)
      PR – Peer Review                 TYPD – Transitional Year Program Director



Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  91
A. Patient Care
        Principal Education Goals                       Learning       Evaluation
                                                        Activities     Methods
    1. Correctly perform a comprehensive evaluation AR, DPC            AE
       of a neonate with suspected surgically
       correctable conditions.
    2. Safely establish percutaneous venous and         DSP. DPC       AE, DSP
       arterial access in neonates over 2 Kg.
    3. Correctly assist in or perform under supervision
       the following procedures:
           a. Peripheral venous cutdown access          DSP, DPC       AE, DSP
            b. Peripheral arterial cutdown access       DSP, DPC       AE, DSP
            c. Placement of umbilical catheters         DSP, DPC       AE, DSP
            d. Placement of central venous access       DSP, DPC       AE, DSP
            e. Tube thoracostomy                        DSP, DPC       AE, DSP
            f. Incision and drainage of superficial     DSP, DPC       AE, DSP
               cysts
            g. Incision and drainage of superficial     DSP, DPC       AE, DSP
               abscesses
            h. Abdominal wall hernia reduction          DSP, DPC       AE,DSP
    4. Accurately and thoroughly record appropriate
       assessments and treatment plans in daily
       progress notes, including:
            a. Ventilator management                    AR, DPC; DSP   AE, DSP
            b. Fluid and electrolyte management         AR, DPC        AE
            c. Nutritional management                   AR, DPC        AE
            d. Antibiotic use                           AR, DPC        AE
    5. Accurately evaluate surgical conditions in the   AE, DPC, MR    AE
       pediatric population through a comprehensive
       history, physical examination and appropriate
       diagnostic studies.
    6. Manage, with appropriate supervision, the
       following common and relatively simple
       surgical problems in the pediatric population:
            a. Integument
             1. Excision of skin lesions                AR, DPC, DSP   AE, DSP
             2. Excision of subcutaneous lesions        AR, DPC, DSP   AE, DSP

                                           92
 3. Incision and drainage of superficial      AR, DPC, DSP   AE, DSP
    abscesses

b. Head and neck
 1.Excision of dermoid cysts                  AR, DPC, DSP   AE, DSP
 2. Excision of small skin lesions            AR, DPC, DSP   AE, DSP
 3. Lymph node biopsy                         AR, DPC, DSP   AE, DSP
c. Thoracic: chest tube placement             AR, DPC, DSP   AE, DSP
d. Cardiovascular                             AR, DPC, DSP   AE, DSP
 1. Central venous catheter placement         AR, DSP, DPC   AE, DSP
 2. Venous cutdown                            AR, DSP, DPC   AE, DSP
 3. Arterial line placement                   AR, DSP, DPC   AE, DSP
e. Gastrointestinal
 1. Pyloromyotomy                             AR, DSP, DPC   AE, DSP
 2. Appendectomy                              AR, DSP, DPC   AE, DSP
 3. Herniorraphy                              AR, DSP, DPC   AE, DSP
       a.   Umbilical                         AR, DSP, DPC   AE, DSP
       b.   Inguinal (in children aged 2 or
           more yrs)
f.   Genitourinary
 1. Circumcision                              AR, DSP, DPC   AE, DSP
 2. orchiopexy                                AR, DSP, DPC   AE, DSP
g. Gynecology
 1. Oophorectomy, simple                      AR, DSP, DPC   AE, DSP
 2. Vaginoscopy – therapeutic                 AR, DSP, DPC   AE, DSP
h. Musculoskeletal
 1. Ganglion cyst excision                    AR,DSP, DPC    AE, DSP
 2. Excision of supernumerary digit           AR, DSP, DPC   AE, DSP
 3. Muscle biopsy                             AR,DSP, DPC    AE, DSP




                               93
B.Medical Knowledge
         Principal Education Goals                            Learning     Evaluation
                                                              Activities   Methods
    1.   The resident should be able to accurately
         describe post-partum transitional physiology,
         including:
            a. Cardiac changes                                AR           AE
            b. Pulmonary changes                              AR           AE
            c. Blood volume changes                           AR           AE
            d. Gastrointestinal changes                       AR           AE
    2.   Accurately describe relevant mechanisms of
         neonatal thermoregulation, including:
            a. Conductive                                     AR, MR       AE
            b. Convective                                     AR, MR       AE
            c. Evaporative                                    AR           AE
            d. Radiant                                        AR           AE
    3.   Accurately discuss how neonatal renal function       AR           AE
         (decreased concentrating ability) affects the
         pharmacokinetics of commonly used drugs.
    4.   Relate the factors influencing immunologic           AR           AE
         immaturity and how this increases susceptibility
         to common neonatal pathogens.
    5.   Describe appropriate fluid and electrolyte           AR           AE
         management of the full-term neonate.
    6.   Accurately calculate the nutritional requirements    AR           AE
         of the full-term neonate and calculate appropriate
         enteral and parenteral nutritional support.
    7.   Accurately describe the embryology of neonatal
         organ systems and their common congenital
         anomalies, including:
            a. Craniocervical
              1. Dermoid cysts                                AR, MR       AE
              2. branchial cleft cysts                        AR, MR       AE
              3. thyroglossal duct cysts                      AR, MR       AE
              4. cystic hygroma                               AR, MR       AE
            b. Foregut


                                           94
 1. Esophageal atresia                       AR         AE
 2. tracheoesophageal fistula                AR, MR     AE
 3. duodenal atresia                         AR         AE
c. Respiratory
 1. cystic adenomatoid malformation          AR         AE
 2. congenital diaphragmatic hernia          AR         AE
d. Cardiac: common cyanotic and acyanotic    AR         AE
   cardiac malformations
e. Foregut:
               1.pyloric stenosis            AR, MR     AE
f.   Midgut:
 1. Intestinal atresia                       AR         AE
 2. intestinal malrotation                   AR         AE
 3. meconium ileus                           AR         AE
 4. intussusceptions                         AR         AE
g. Hindgut:

               1.Hirschsprung’s disease      AR, DPC,   AE
                                             MR, GR
               2.imperforate anus            AR, DPC,   AE
                                             MR, GR
               3.meconium plug syndrome      AR, DPC,   AE
                                             MR, GR
               4,small left colon syndrome   AR, DPC,   AE
                                             MR, GR
h. Body wall defects:
 1. Gastroschisis                            AR, DPC,   AE
                                             MR, GR
 2. Omphalocele                              AR, DPC,   AE
                                             MR, GR
 3. Umbilical hernia                         AR, DPC,   AE
                                             MR, GR
 4. Inguinal hernia                          AR, DPC,   AE


                             95
                                                       MR, GR
              5. Urachal malformations                 AR, DPC,   AE
                                                       MR, GR
         i.     Renal
              1. Polycystic kidneys                    AR, DPC,   AE
                                                       MR, GR
              2. Ureteral obstruction                  AR, DPC,   AE
                                                       MR, GR
              3. Vesicoureteral reflux                 AR, DPC,   AE
                                                       MR, GR
         j.     Lower GU tract                         AR, DPC,   AE
                                                       MR, GR
              1. Urethral valves                       AR, DPC,   AE
                                                       MR, GR
              2. Hypospadias                           AR, DPC,   AE
                                                       MR, GR
              3. Undescended testis                    AR, DPC,   AE
                                                       MR, GR
              4. Testicular torsion                    AR, DPC,   AE
                                                       MR, GR
         k. Inborn and genetic error                   AR, DPC,   AE
                                                       MR, GR
              1. Trisomy 13                            AR, DPC,   AE
                                                       MR, GR
              2. Trisomy 21                            AR, DPC,   AE
                                                       MR, GR
              3. down’s syndrome                       AR, DPC,   AE
                                                       MR, GR
8.  Accurately describe the diagnosis, preoperative    AR, DPC    AE
    evaluation, and management of the common
    congenital anomalies listed in number 7, above.
9. Accurately relate current theories on the           AR, DPC    AE
    pathophysiology of necrotizing enterocolitis.
10. Accurately describe the arterial and venous        AR, DPC    AE
    anatomy of the neonate.
11. Outline the technical principles involved in the
    following procedures:
         a. Gastrostromy                               AR, DSP    AE

                                         96
         b. Colostomy                                AR,DSP              AE
         c. Inguinal hemiorrhaphy                    AR, DSP   AE
         d. Umbilical herniorrhaphy                  AR, DSP   AE
         e. Circumcision                             AR, DSP   AE
         f.   Central venous access                  AR, DSP   AE
12. Accurately outline the perioperative care of
    neonates, including:
         a. Basic ventilator management              LL, AR,   AE
                                                     DPC
         b. Fluid and electrolyte management         AR, DPC   AE
         c. Nutritional management                   AR, DPC   AE
         d. Correction of coagulopathies             AR, DPC   AE
         e. Indications for transfusion              AR, DPC   AE
         f.   Diagnosis of sepsis and antibiotic     AR, DPC   AE
              utilization
13. Accurately describe normal development of
    children with respect to:
         a. Weight, length and head size             AR, DPC   AE
         b. Nutritional requirements                 AR, DPC   AE
         c. Renal function                           AR, DPC   AE
         d. Hormonal influences on development       AR, DPC   AE
         e. Response to stress and infection         AR, DPC   AE
14. Accurately describe the technical steps in the   DSP       AE, DSP
    following procedures:
        a) Excision of skin and subcutaneous
           lesions
        b) Incision and drainage of abscesses
        c) Lymph node biopsy
        d) Chest tube placement
        e) Oral intubation
        f) Inguinal herniorrhaphy

         a. Excision of skin and subcutaneous        DSP       AE, DSP
            lesions
         b. Incision and drainage of abscesses       DSP       AE, DSP
         c. Lymph node biopsy                        DSP       AE, DSP
         d. Chest tube placement                     DSP       AE, DSP


                                       97
             e. Oral intubation                                  DSP       AE, DSP
             f.   Inguinal herniorrhaphy                         DSP       AE, DSP
    15. Accurately describe the components of pre- and           DPC       AE, DSP
        post- operative care of infants and children who
        undergo the procedures listed in number 14,
        above
    16. List the common causes and explain the                   GR, MR,   AE
        diagnosis and treatment of gastrointestinal              AR, DPC
        hemorrhage in the neonate, infant, child and
        adolescent.

C.Interpersonal Skills and Communication

        Principal Education Goals                           Learning       Evaluation
                                                            Activities     Methods
    1. Clearly, accurately and succinctly present           LL, AR         AE
       pertinent information to faculty regarding
       patients new to the service including newly
       admitted patients and patients for whom the
       service has been consulted.
    2. Clearly, accurately and respectfully communicate     LL, AR         AE
       with nurses and other hospital employees.
    3. Clearly, accurately and respectfully communicate     LL, AR         AE
       with patients and appropriate members of their
       families identified disease processes (including
       complications), the expected courses, operative
       findings and operative procedures.
    4. Maintain clear, concise, accurate and timely         AR             AE
       medical records including (but not limited to)
       admission history and physical examination
       notes, consultation notes, progress notes, orders,
       operative notes and discharge summaries .

D. Professionalism

        Principal Education Goals                           Learning       Evaluation
                                                            Activities     Methods
    1. Be honest with all individuals at all times in       LL, AR         AE
       conveying issues of patient care.
    2. Place the needs of the patient above the needs or    LL, AR         AE
       desires of self.
    3. Maintain high ethical behavior in all professional   LL, AR         AE
       activities.
    4. Demonstrate commitment to continuity of care         LL, AR         AE

                                           98
         through carrying out her/his own personal
         responsibilities or through assuring that those
         responsibilities are fully and accurately conveyed
         to others acting in her/his stead.
    5.   At any time while engaged in patient care, is         LL           AE
         properly and professionally attired including
         adherence to any extant dress code.
    6.   Demonstrate sensitivity to issues of age, race,       LL, AR       AE
         gender and religion with patients, families and all
         members of the health care team.
    7.   At all times treat patients, families and all         LL, AR       AE
         members of the health care team with respect.
    8.   Reliably be present in pre-arranged places and at     LL           AE
         pre-arranged times except when the resident is
         actively engaged in the treatment of a surgical or
         medical emergency. Under such circumstances,
         the resident should provide timely notification to
         the appropriate individual(s) of her/his inability
         to engage in the pre-arranged activity.




E. Practice-Based Learning and Improvement

         Principal Education Goals                             Learning     Evaluation
                                                               Activities   Methods
    1. Maintain a detailed log of procedures and               DSP, AP      AE
       operative cases in which (s)he participates
       including:
           A. Diagnosis                                        DSP, AP      AE, TYPD
             B. Procedure performed                            DSP, AP      AE, TYPD
             C. Postoperative course of the patient            DSP, AP      AE, TYPD
                 including any complications sustained
                 and an analysis of the origins of each
                 complication.
    2.   Maintain a portfolio of rotation related literature   AP           AE, TYPD
         searches.
    3.   Maintain a portfolio of rotation related formal       AP           AE, TYPD
         presentations including presentation of
         complications (Morbidity and Mortality
         Conference).




                                             99
F. Systems Based Practice

         Principal Education Goals                            Learning     Evaluation
                                                              Activities   Methods
    1. Appropriately utilize in a timely and cost
       efficient manor ancillary services including:
           A. Social work                                     AS, AR       AE
             B. Discharge planning                            AS, AR       AE
             C. Physical therapy                              AS, AR       AE
             D. Occupational therapy                          AS, AR       AE
             E. Respiratory therapy                           AS, AR       AE
             F. Nutrition services                            AS, AR       AE
             G. Pharmacists                                   AS, AR       AE
             H. Physician extenders including                 AS, AR       AE
                 physicians’ assistants and nurse
                 practitioners
    2.   Summarize the financial costs, the risks and the     AR, MR       AE
         benefits of all proposed diagnostic studies and
         therapeutic interventions.
    3.   Offer sound justification for all diagnostic tests   AR, MR, MM   AE
         (including laboratory studies) ordered by
         her/him.




                                             100
          SURGICAL CRITICAL CARE – MEMORIAL HERMANN HOSPITAL

The Memorial Hermann Hospital Surgical Critical Care rotation is a one month rotation to which
Transitional Year Residents are assigned. Transitional Year Residents work on a team with one
faculty member, one Fellow (team leader), PGY 2 Surgery Resident, PGY 3 Emergency
Medicine Resident, and PGY 2 Emergency Medicine Resident and up to three interns. The
transitional year resident is supervised by the faculty member and fellow. During this rotation the
Transitional Year resident will learn about the pathophysiology of shock and its categories;
demonstrate an understanding of the mechanisms and pathophysiology of cardiopulmonary
arrest; demonstrate the ability to manage the treatment of shock and cardiopulmonary arrest;
demonstrate knowledge of the principles associated with the diagnosis and management of
critically-ill patients including knowledge of simple and complex multiple organ system
normalities and abnormalities; and demonstrate the ability to appropriately diagnose and treat
patients with interrelated system disorders in the intensive care unit.

Call is every third night supervised by PGY2 or PGY 3 Resident with a faculty member taking
call from home. Adherence to the 80-hour work week is mandated.

Legend for Learning Activities
AR-Attending Rounds                             CC – Core Curriculum
DPC – Direct Patient Care                       DSP – Directly Supervised Procedures
EBM – Evidence Based Medicine                   FS – Faculty Supervision
GR – Grand Rounds                               IL – Introductory Lecture Series
LL – Lunch & Learn                              MR-Morning Report

Legend for Evaluation of Methods for Residents
AE – Attending Evaluations               DSP – Directly Supervised Procedures
MR – Morning Report                      PDR – Program Director’s Review (quarterly)
PR – Peer Review                         TYPD – Transitional Year Program Director


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  101
A. Patient Care
         Principal Education Goals                           Learning     Evaluation
                                                             Activities   Methods
    1. Describe the criteria for predicting preoperatively
       the patient’s need for critical
                 care, including:
           a. pre-existing disease states (cardiac,          AR, DPC      AE
               pulmonary, or renal)
           b. operation-specific requirements for            AR, DPC      AE
               postoperative intensive care
               management

B. Medical Knowledge
         Principal Education Goals                           Learning     Evaluatn
                                                             Activities   Methods
    1.    Define the categories of shock based upon type:
             a. Hypovolemic                                  AR, DPC,     AE
                                                             GR
             b. Cardiogenic                                  AR, DPC,     AE
                                                             GR
             c. Septic                                       AR, DPC,     AE
                                                             GR
             d. Neurogenic                                   AR, DPC,     AE
                                                             GR
             e. Anaphylactic                                 AR, DPC,     AE
                                                             GR
             f. Thermogenic (hypo-and hyper-                 AR, DPC,     AE
                thermia)                                     GR
    2.    Explain the etiology and pathophysiology of
          each type of shock.
                  a.     Hypovolemic                         AR, DPC,     AE
                                                             GR
                  b.     Cardiogenic                         AR, DPC,     AE
                                                             GR
                  c.     Septic                              AR, DPC,     AE
                                                             GR
                  d.     Neurogenic                          AR, DPC,     AE
                                                             GR

                                         102
            e.      Anaphylactic                    AR, DPC,   AE
                                                    GR
            f.      Thermogenic (hypo-and           AR, DPC,   AE
                 hyper-thermia)                     GR
3    Summarize the clinical presentation and
     hemodynamic parameters associated
     with each type of shock.
            a.      Hypovolemic                     AR, DPC,   AE
                                                    GR
            b.      Cardiogenic                     AR, DPC,   AE
                                                    GR
            c.      Septic                          AR, DPC,   AE
                                                    GR
            d.      Neurogenic                      AR, DPC,   AE
                                                    GR
            e.      Anaphylactic                    AR, DPC,   AE
                                                    GR
            f.      Thermogenic (hypo-and           AR, DPC,   AE
                 hyperthermia)                      GR
4.   Propose an algorithm for diagnosing and
     initiating treatment for each shock type.
            a.      Hypovolemic                     AR, DPC,   AE
                                                    GR
            b.      Cardiogenic                     AR, DPC,   AE
                                                    GR
            c.      Septic                          AR,DPC,    AE
                                                    GR
            d.      Neurogenic                      AR, DPC,   AE
                                                    GR
            e.      Anaphylactic                    AR, DPC,   AE
                                                    GR
            f.      Thermogenic (hypo-and           AR, DPC,   AE
                 hyperthermia)                      GR
5    Explain the concepts of tissue oxygen supply
     and demand. Demonstrate the contributions
     from the following components:
        a. calculate oxygen delivery                AR, DPC    AE




                                    103
        b. calculate oxygen consumption                AR, DPC   AE

        c. analyze the effect of cardiac output        AR, DPC   AE
            and
      varying preload, pump, and afterload to oxygen
        delivery
        d. analyze the contributions of                AR, DPC   AE
            hemoglobin and percent of
            saturation on oxygen delivery
        e. explain the changes in tissue oxygen        AR, DPC   AE
            delivery and uptake related to pH,
         Temperature, 2, 3-diphosphoglyceride
            (DPG).

6.           Discuss the evaluation and treatment      AR, DPC   AE
               of the following bleeding disorders

        a. the role of blood vessels, platelets,       AR, DPC   AE
           fibrin cascade and degeneration in
           normal hemostasis
        b. Disseminated intravascular                  AR, DPC   AE
           coagulopathy (DIC), defining
           common causes and therapy
        c. Thrombocytopenia as a failure of            AR, DPC   AE
           production, accelerated destruction,
           or dilution
        d. Hemophilia A                                AR, DPC   AE

        e. VonWillebrand’s disease                     AR, DPC   AE

        f. Idiopathic thrombocytopenia purpura         AR, DPC   AE
           (ITP) and thrombotic
           thrombocytopenia purpura (TTP) as
           causes of thrombocytopenia
           (compare and contrast)
        g. Heparin or Coumadin therapy                 AR, DPC   AE
           misapplication
        h. Advanced liver disease                      AR, DPC   AE

        i.   The role of protein C, S, and lupus       AR, DPC   AE
             circulating anticoagulant and their
             roles in bleeding disorders
7.   Discuss the pathophysiology, including the
     mechanism of arrest for each of the following
     situations

                                    104
        a. Acute myocardial infarction               AR, DPC    AE

        b. Acute dysrhythmias                        AR, DPC    AE

        c. Congestive heart failure                  AR, DPC    AE

        d. Pulmonary embolus                         AR, DPC,   AE
                                                     GR
        e. Tension pneumothorax                      AR, DPC,   AE
                                                     GR
        f. Penetrating or blunt trauma               AR, DPC,   AE
                                                     GR
        g. Substance abuse                           AR, DPC    AE

        h. Suffocation                               AR, DPC    AE

        i.   Drowning                                ARD, PC,   AE
                                                     GR
        j.   Hypothermia                             AR, DPC,   AE
                                                     GR
        k. Electrical injury                         AR, DPC,   AE
                                                     GR
        l.   Acute stroke                            AR, DPC,   AE
                                                     GR
        m. Burns                                     AR, DPC,   AE
                                                     GR
        n. Hemorrhagic shock                         AR, DPC,   AE
                                                     GR
8.   Explain the indications for and the potential
     complications of the following drugs
        a. lidocaine                                 AR, DPC    AE

        b. bretylium                                 AR, DPC    AE

        c. digoxin                                   AR, DPC    AE

        d. diltiazem                                 AR, DPC    AE

        e. procainamide                              AR, DPC    AE

        f. labetalol                                 AR, DPC    AE



                                     105
         g. esmolol                                      AR. DPC    AE

         h. adenosine                                    AR, DPC    AE

9.  Summarize the indications and appropriate            AR,        AE, DSP
    techniques for cardioversion and                     DSP,DPC
    defibrillation.
11. Explain the physiological impact of                  AR, DPC    AE
    mechanically assisted ventilation on the
    cardiovascular/respiratory system.
12. Be able to initiate and maintain ventilatory         AR, DPC,   AE, DSP
    support.                                             DSP
13. Explain the etiology and treatment of carbon         AR, DPC    AE
    monoxide poisoning.
14. Describe the indications and potential
    complications for the following
    interventions:
        a. central venous catheter;                      AR, DPC,   AE
                                                         DSP
         b. arterial line                                AR, DPC,   AE
                                                         DSP
         c. thoracostomy tube                            AR, DPC,   AE
                                                         DSP
         d. thoracentesis                                AR, DPC,   AE
                                                         DPS
         e. endotracheal intubation (oral and            AR.        AE
          nasal).                                        DPC,DSP

15. Review the importance of serial physical             AR, DPC    AE
    examinations, hemodynamic monitoring, and
    serial laboratory evaluations in assessing patient
    response to specific resuscitation treatment.
16. Outline the clinical and laboratory indications
    for transfusion of the following blood products:
        a. packed red cells                              AE, DPC    AE

         b. fresh frozen plasma                          AE, DPC    AE

         c. platelets                                    AE, DPC    AE

         d. cryoprecipitate                              AE, DPC    AE


                                     106
         e. whole blood                                 AE, DPC   AE

17. Analyze the potential complications from use of     AE, DPC   AE
    the above products.
18. Describe the role and indications for the
    following products in acute resuscitation:
        a. desmopressin acetate                         AE, DPC   AE

         b. Hespan or similar products (DDAVP)          AE, DPC   AE

         c. albumin                                     AE, DPC   AE

19. Assess the indications, guidelines, and potential
    complications of the following cardiovascular
    drugs:
       a. dopamine                                      AE, DPC   AE

         b. dobutamine                                  AE, DPC   AE

         c. phenylephrine                               AE, DPC   AE

         d. epinephrine                                 AE, DPC   AE

         e. norepinephrine                              AE, DPC   AE

         f. milrinone                                   AE, DPC   AE

20. Discuss the use of sepsis severity scores           AE, DPC   AE

21. Describe the normal physiologic response to a       AE, DPC   AE
    variety of insults such as sepsis, trauma, or
    surgery by associating the adaptation of the
    following systems from their pre-stress to post-
    stress states:
        a. respiratory                                  AE, DPC   AE

         b. hemodynamic                                 AE, DPC   AE

         c. renal                                       AE, DPC   AE

         d. metabolic                                   AE, DPC   AE




                                    107
         e. endocrine                                    AE, DPC   AE

22. Describe prophylactic measures routinely used
    in critical care such as:

         a. gastrointestinal (GI) bleeding               AE, DPC   AE
            prophylaxis
         b. prophylactic antibiotics                     AE, DPC   AE
               (demonstrate differences between true
                 prophylaxis, empiric and
                 therapeutic
               uses)
         c. pulmonary morbidity prophylaxis              AE, DPC   AE
            (incentive spirometry);
         d. venous                                       AE, DPC   AE
          thromboembolic event prophylaxis

         e. aseptic technique                            AE, DPC   AE

         f. universal precautions                        AE, DPC   AE

         g. skin care protocols                          AE, DPC   AE

23. Discuss the pharmacotherapeutics of drugs used
    for support and treatment of the critically ill
    patient with emphasis on mode of action,
    physiologic effects, spectrum of effects, duration
    of action, appropriate doses, means of
    metabolism or excretion, complications and
    cost:
        a. vasopressors                                  AR, DPC   AE

         b. vasodilators                                 AR, DPC   AE

         c. inotropic agents                             AR, DPC   AE

         d. inotropic agents                             AR, DPC   AE

         e. antibiotics/antifungal agents;               AR. DPC   AE

         f. diuretics                                    AR, DPC   AE

         g. bronchodilators                              AR, DPC   AE


                                    108
         h. antihypertensives                           AR, DPC   AE

         i.   antidysrhythmics                          AR, DPC   AE

24. Outline the indications and methods for
    providing nutritional support by completing the
    following activities
        a. discuss indications, selection of            AR, DPC   AE
              formulations, cost, route of
                 administration of parenteral versus
                 enteral forms of nutrition
        b. explain complications of parenteral          AR, DPC   AE
            and enteral routes of feeding as
              well as select methods to avoid the
                 complications
        c. interpret findings                           AR, DPC   AE
              associated with abnormalities in levels
                 of glucose, chloride, sodium,
                 phosphate, magnesium, trace
                 metals/elements, and vitamins in
                 the critically-ill patient receiving
                 enteral or parenteral feedings
        d. estimate protein calorie requirements        AR, DPC   AE
              for patients of varying degrees of
                 illness, and be able to analyze
                 adequacy of nutritional support
                 using commonly obtainable
                 laboratory values.
25. Outline the principles of postoperative fever       AR, DPC   AE
    with respect to causes, empiric diagnostic
    modalities and specific therapy.
26. Describe, apply, and revise appropriate
    treatment intervention based upon analysis of
    changes in the patient’s clinical and laboratory
    parameters: adjustment of intravenous fluids
    with respect to expected stress response,
    including metabolic, hormonal, cardiovascular,
    and renal responses to replacement of fluid
    losses:
        A. efficacy of prophylactic measures            AR, DPC   AE

         B. adequacy of nutritional support in a        AR, DPC   AE
            patient with multiple sites of protein
            losses (e.g., fistulas, drain sites, or
            metabolic stressors)

                                    109
        C. analysis and treatment of                       AR, DPC   AE
            postoperative fever and methods of
            treatment
        D. events leading to and responsible for           AR, DPC   AE
            initiation of ventilatory support
        E. differentiate low cardiac output,               AR, DPC   AE
            hypotensive/ hypertensive states in
            terms of preload, pump, or afterload
        F. analysis and treatment of seizures              AR, DPC   AE
            including role of ABC’s, electrolytes,
            glucose/thiamine IV, antiepileptic
            drugs
        G. analysis and treatment of acute                 AR, DPC   AE
            respiratory failure from changes in
            the airway, pump, or lung.
27. Review the management and diagram a plan for
    the care of the critically ill surgical patient with
    multiple medical problems such as
        a. cardiac dysrhythmias                            AR, DPC   AE

         b. pulmonary insufficiency                        AR, DPC   AE

         c. acute/chronic renal failure                    AR, DPC   AE

         d. diabetes mellitus and its problems that it     AR, DPC   AE
            poses for nutritional support
         e. hemodynamic instability in the face of         AR, DPC   AE
            acute/chronic renal or pulmonary
            insufficiency
28. Describe the commonly used indications for
    initiation of ventilation support, Including
         a. Indications and commonly                       AR, DPC   AE
             acceptable values for initiation of
             mechanical ventilation
         b. evaluation of airway                           AR, DPC   AE

         c. evaluation of adequacy of thoracic             AR, DPC   AE
            pump (muscle strength)
         d. evaluation of lung parenchymal                 AR, DPC   AE
            characteristics
         e. analysis of commonly used                      AR, DPC   AE
            pulmonary values such as tidal
            volume, PEEP, auto PEEP,
            compliance (static and dynamic),
            functional residual capacity, airway

                                      110
              pressures

        f. indications and commonly                    AR, DPC   AE
            acceptable values for weaning from
            mechanical ventilation
29. Review respiratory physiology, and describe the    AR, DPC   AE
    specific pathology involved in ventilation and
    perfusion deficits.
30. Analyze and compare the principles of ventilator   AR, DPC   AE
    mechanics, including modes of ventilation,
    triggering mechanisms, and possible uses.
31. Describe the pathophysiology of acute lung
    injury and the management of the long-term
    ventilator-dependent patient to include:
        a. pneumonias                                  AR, DPC   AE

         b. acute renal failure                        AR, DPC   AE

         c. cardiac failure                            AR, DPC   AE

         d. prevention of malnutrition or              AR, DPC   AE
            restitution of body stores
         e. systemic inflammatory response             AR, DPC   AE
            syndrome (SIRS)
         f. sepsis                                     AR, DPC   AE

         g. skin care problems                         AR, DPC   AE

         h. physical therapy                           AR, DPC   AE

         i.psychological support for both              AR, DPC   AE
           patient and family
32. Discuss the use of the following drugs to
    improve respiratory function:
       a. Bronchodilators                              AR, DPC   AE

         b. membrane stabilizing agents                AR, DPC   AE

         c. diuretics                                  AR, DPC   AE

         d. venodilators                               AR, DPC   AE




                                   111
         e. analgesics and sedatives                     AR, DPC   AE

         f. mucolytics                                   AR, DPC   AE

33. Describe and compare the following cardiac
    function parameters:
       a. Preload                                        AE, DPC   AE

         b. Afterload                                    AE, DPC   AE

         c. myocardial contractility                     AE, DPC   AE

34. Define the information obtained from the use of
    the following invasive/noninvasive monitoring
    devices. Specify: which information is
    directly/indirectly measured or calculated, the
    accuracy, and cost of obtaining the information,
    and review the hemodynamic principles
    associated with the use of each device:
        a. arterial catheters                            AR, DPC   AE

         b. central venous catheters                     AR, DPC   AE

         c. Swan-Ganz catheters                          AR, DPC   AE

         d. intracranial pressure monitors               AR, DPC   AE

         e. end tidal carbon dioxide monitors            AR, DPC   AE

         f. pulse oximetry                               AR, DPC   AE

         g. peripheral nerve stimulators                 AR, DPC   AE

         h. Foley catheters                              AR, DPC   AE

         i.   intestinal pH monitors.                    AR, DPC   AE

35. Outline the protocols for definition of patterns
    and management of hemodynamically unstable
    patients, and analyze the selection of appropriate
    therapy by completing these activities:
        a. predict improvements in                       AR, DPC   AE
            hemodynamic status with
            manipulation of definable variables,

                                    112
            including fluid and drug therapies

        b. detect and revise therapies based on         AR, DPC   AE
            the use of invasive/noninvasive
            monitoring devices
36. Review cardiac function and hemodynamic
    monitoring from the following standpoints.
    Interpret changes in accuracy of values obtained
    from hemodynamic monitoring devices in
        a. patients with severe pulmonary               AR, DPC   AE
            insufficiency who have low
            compliances or high PEEP
        b. patients with severe valvular                AR, DPC   AE
            insufficiency/stenosis
        c. various shock states (hypovolemic,           AR, DPC   AE
            septic, spinal, or cardiogenic)
37. Summarize the effects of appropriate volume
    and drug therapies to manipulate the
    cardiovascular system in the following patients:
        a. hypovolemic hypotensive patient              AR, DPC   AE

         b. hypotensive euvolemic patient               AR, DPC   AE

         c. hypotensive hypervolemic patient            AR, DPC   AE

         d. hypotensive oliguric patient                AR, DPC   AE

         e. hypotensive, hypervolemic oliguric          AR. DPC   AE
            patient
         f. hypovolemic oliguric patient                AR, DPC   AE

         g. hypotensive, oliguric hypoxic patient       AR, DPC   AE

38. Review acid-base and electrolyte abnormalities      AR, DPC   AE
    common in critically-ill patients.
39. Identify, define, and classify the major
    categories of acid-base disturbance (metabolic
    acidosis and/or alkalosis, respiratory acidosis
    and/or alkalosis) in the context of the patient’s
    altered physiology. Cite common clinical
    scenarios for their appearance:
        a. metabolic acidosis (hypovolemic              AR, DPC   AE
            shock, chloride excess resuscitation,
            occult ischemia)

                                    113
         b. metabolic alkalosis                         AR, DPC   AE

         c. respiratory acidosis                        AR, DPC   AE

40. Discuss the identification and correction of
    complex acid-base problems such as choice of
    intravenous fluids for electrolyte replacement in
    the:
         a. hyperchloremic, metabolically-              AR, DPC   AE
             acidotic patient
         b. hypochloremic, metabolically-               AR, DPC   AE
             alkalotic patient
         c. stuporous, dehydrated,                      AR, DPC   AE
             hypernatremic patient
         d. patient with central diabetes               AR, DPC   AE
             insipidus
         e. hyponatremic, volume overloaded             AR, DPC   AE
             patient with carbon dixoide retention
41. Discuss the physiologic principles and define
    specific management aspects associated with the
    following complex acid-base problems:
         a. renal tubular acidosis (differentiate       AR, DPC   AE
             between Type I and II)
         b. management of high output loss              AR, DPC   AE
             states from the gastrointestinal tract
             in a patient with poor cardiac
             function
         c. management of volume excess                 AR, DPC   AE
             states associated with eunatremia or
             hyponatremia
42. Review and summarize the management of renal        AR, DPC   AE
    failure, including: (a) current means for support
    of renal failure, continuous veno-venous
    hemofiltration (CWH), continuous veno-venous
    hemodialysis (CWHD); dialysis (peritoneal and
    hemodialysis.
43. Describe and specify therapy for the following
    endocrine-related problems associated with
    critical care:
         a. hypothyroidism/hyperthyroidism              AR, DPC   AE

         b. hyperparathyroidism/hypoparathyroid         AR, DPC   AE
            ism (changes in calcium and
            magnesium values)

                                    114
                c. adrenal cortical excess (Cushing’s              AR, DPC       AE
                    disease and syndrome
                d. adrenal cortical deficiency states              AR, DPC       AE
                    (Addison’s disease)
         44. Describe the initial evaluation, ongoing, acute
             monitoring and long-term management of
             commonly occurring neurologic problems in the
             ICU setting:
                a. Seizures                                        AR, DPC       AE

                  b. Coma                                          AR, DPC       AE

                  c. hemorrhagic stroke                            AR, DPC       AE

                  d. thromboembolic stroke                         AR, DPC       AE

         45. Describe the initial management of traumatic          AR, DPC       AE
             brain injury (a) first tier therapy (ventricular
             draining, sedation).

     C.Interpersonal Skills and Communication

             Principal Education Goals                          Learning         Evaluation
                                                                Activities       Methods
         1. Review and interpret the relationships of           AR, LL           AE, TYPD
            physicians, nurses, and administrators in
            managing patients assigned to the ICU.

     D. Professionalism


                                                                Learning         Evaluation
        Principal Educational Goals                                              Methods
                                                                 Activities
1.     Interact professionally toward towards patients,
       families, colleagues, and all members of the health     DPC, AR, MR, LL   AE,TYPD
       care team.
2.     Acceptances of professional responsibility as the                         AE
                                                               DPC, AR, MR, PC
       primary care physician for patients under his/her care.
3.                                                             DPC, AR, MR,      AE, TYPD
       Appreciation of the social context of illness.
                                                                 LL, PC
4.     Knowing when and how to request ethics                                    AE, TYPD
       consultation, and how best to utilize the advice        DPC, AR, PC,LL
       provided.

                                              115
5.     Understand ethical concepts of confidentiality,                           AE, TYPD
                                                               DPC, AR, PC, LL
       consent, autonomy and justice.
6.     Understand professionalism concepts of integrity,                         AE, PDR
                                                               DPC, PC
       altruism and conflict of interest.
7.     Increase self-awareness to identify methods to
       manage personal and professional sources of stress      PC, NC, GR        PDR
       and burnout.
8.     Increase knowledge and awareness of personal risks
       concerning drug/alcohol abuse for self and                                PDR
                                                               PC, NC, GR
       colleagues, including referral, treatment and follow-
       up.




     E. Practice-Based Learning and Improvement

             Principal Education Goals                          Learning         Evaluation
                                                                Activities       Methods
         1. Be able to successfully perform the following
            procedures:
               a. orotracheal and nasotracheal                  DSP, DPC         AE, DSP
                   intubation
               b. Foley catheter placement                      DSP, DPC         AE, DSP
                 c. central venous catheter insertion           DSP, DPC         AE, DSP
                    (subclavian approach, internal
                    jugular approach, femoral
                    approach)
                 d. pleurocentesis                              DSP, DPC         AE, DSP
                 e. lumbar puncture                             DSP, DPC         AE

     F. Systems Based Practice

             Principal Education Goals                          Learning         Evaluation
                                                                Activities       Methods
         1. Summarize the following moral and ethical
            problems encountered in the ICU:
               a. the need for organ donation and               AR, DPC, GR      AE
                   the identification of potential donors
               b. decisions about whom to                       AR, DPC, LL      AE
                   resuscitate and to what degree
               c. care for the mentally incapacitated           LL, AR, DPC      AE

                                               116
   or incompetent patient
d. dealing with a difficult family and     LL, AR, DPC   AE
   futility of care
e. identifying and interacting with        LL, AR, DPC   AE
   alternate religious/cultural beliefs.




                            117
                          Burns Surgery – Memorial Hermann Hospital
Transitional Year residents assigned to Memorial Hermann Burn Surgery, a combined service
with Plastic Surgery work on a team with two faculty members, one fellow (team leader, PGY 6
or 7) and one or two interns. The rotation is one month. The Burn Unit has 10 ICU beds and 6
floor beds. The transitional year resident is supervised by the fellow and the faculty. The resident
works closely with ancillary staff such as the nutritionist, wound care specialist, physical
therapist, occupational therapist, recreational therapist and social worker. During this rotation
residents will gain knowledge in basic assessment and overall management of patients sustaining
burn injuries; be able to demonstrate and understanding of the concepts of burn injury and its
pathophysiology; and demonstrate the ability to apply these concepts to the evaluation,
resuscitation, clinical management, and rehabilitation of the burned patient.

Call is every third or fourth night, with every third call combined with face coverage supervised by
a Plastic Fellow (PGY 6 or 7); as the Burns Service is combined with Plastic Surgery with
attendings on this service covering both specialties. Adherence to the 80-hour work week is
mandated.


      Legend for Learning Activities
      AR-Attending Rounds                                CC – Core Curriculum
      DPC – Direct Patient Care                          DSP – Directly Supervised Procedures
      EBM – Evidence Based Medicine                     FS – Faculty Supervision
      GR – Grand Rounds                                 IL – Introductory Lecture Series
      LL – Lunch & Learn                                AS –Ancillary Staff
      AP – Alpha Portfolio




      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations         TYPD – Transitional Year Program Director
      DSP – Directly Supervised Procedures
      PR – Peer Review




Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  118
A. Patient Care
         Principal Education Goals                             Learning       Evaluation
                                                               Activities     Methods
    1.   Correctly assess a burn wound in relation to its      DPC, AR, AS    AE
         depth, percentage of body surface area involved,
         bacteriologic condition, healing potential, and
         requirement for intervention.
    2.   Recognize clinical factors necessitating immediate    DPC, AR        AE
         intervention to preserve life, limb, and function.
    3.   Generate an appropriate initial treatment plan        DPC, DSP, LL   AE, DSP
         for stabilization and fluid resuscitation of a
         burned patient based on the above
         evaluation.
    4.   Correctly perform in the burn patient:
             a. Initial wound evaluation                       DSP, DPC, AS   AE, DSP
             b. Emergency management including:
                  1.    Installation of appropriate lines      DSP, DPC       AE, DSP
                     and devices
                  2.    Fluid resuscitation                    AR, FS, DPC    AE
                  3.     Monitoring                            DPC, FS, AP    AE
             c. Wound management including                     AR, DPC, AS    AE
                emergent and subsequent surgical
                intervention
             d. Generation of an appropriate initial           AR, DPC        AE
                treatment plan for stabilization and
                fluid resuscitation
             e. Pharmacological usage including                AR, LL, DPC    AE
                analgesia, topical antibiotics and
                systemic antibiotics
             f. Nutritional support methods                    AS, AR, DPC    AE
             g. Local wound care with topical agents           AR, DPC        AE
              h. Synthetic, biosynthetic and biological        AR, DPC        AE
                  dressings
    5.   Safely and appropriately perform harvest,             AR, DPC, DSP   AE
         application, immobilization, and care of split- and
         full- thickness skin grafts in burn patients.

    6.   Correctly identify and manage complications in
         the burn patient including:
             a. Sepsis                                         AR, DPC        AE
             b. Gastrointestinal (GI) effects                  AR, DPC        AE


                                          119
             c. Immunologic problems                       AR, DPC        AE
             d. Cardio-respiratory effects                 AR, DPC        AE
             e. Abdominal compartment syndrome             AR, DPC        AE
    7.    Recognize inhalation injury and with faculty
          supervision perform:
             a. Ventilator management                      AR, DPC, AS    AE
    8.    Recognize and appropriately manage carbon        AR, DPC        AE
          monoxide poisoning.
    9.    Correctly perform with supervision in the burn
          patient:
              a. Debridement of deep tisues                AR, DPC        AE
             b. Split-thickness skin graft harvest and     AR, DPC, DSP   AE
                  application
    10.   Correctly evaluate electrical burns, including
             a. Entrance and exit wounds                   AR, DPC        AE
             b. Cardiac, vascular, neurologic,             AR, DPC        AE
                ophthalmologic effects
             c. Deep tissue destruction                    AR, DPC        AE
             d. Rhabdomyolysis                             AR, DPC        AE
    11. Institute treatment of chemical burns including:
             a. Identification of types and sources        DPC, AR        AE
             b. Management by dilution or                  DPC, AR        AE
                neutralization
             c. Treatment of systemic effects of local     DPC, AR        AE
                chemicals




B. Medical Knowledge

          Principal Education Goals                        Learning       Evaluation
                                                           Activities     Methods
    1.    Demonstrate a basic understanding of the
          local pathophysiological events and
          systemic pathophysiological events
          following a cutaneous burn injury
          including:
              a. Pathological changes in the skin          AR, DPC, AS    AE
             b. Subsequent systemic alterations
                including:

                                          120
         1. Fluid and electrolyte perturbation         AR,DPC         AE

         2. Acid-base abnormalities                    AR, DPC        AE

         3. Hematological events                       AR, DPC        AE

         4. Hemodynamic alterations including          AR, DPC        AE
             cardiac and renal changes should
            be understood as well as
         5. Pulmonary alterations resulting from       AR, DPC        AE
            inhalation or distant cutaneous injury

2.    Clearly discuss pertinent aspects of the         AR, DPC, AS    AE
      epidemiology, prevention, and
      socioeconomic and psychological effects of
      burns.
3.    Describe the histological and functional         AR, DPC        AE
      anatomy of the skin, adnexa, and
      subcutaneous tissues.
4.    Outline the physics and dynamics of thermal      AR, DPC        AE
      injury and the progression of tissue damage.
5.    Describe the criteria for adequate evaluation    AR             AE
      of a burned patient, including historical
      aspects of the type of burn and subjective
      physical findings.
6.    List the clinical factors necessitating          AR, DPC, DSP   AE
      immediate intervention to preserve life, limb,
      and function in the burn patient.
7.    Outline the principles of:
         a. Burn shock                                 AR, DPC        AE
          b. Immunologic alteration in the burn        AR, DPC        AE
              patient
          c. Bacteriological pathology of burned       AR, DPC        AE
              skin
8.    Recite the “Rule of Nines” as it relates to      AR             AE
      total body surface area of a burn.
9.    Describe the relationship between burn           AR, AS, DPC    AE
      depth and the degree of the burn.
10.   Describe the principles of use of systemic       AR, AS         AE
      and local antibacterial agents in the burn
      wound.
11.   Explain the special circumstances created by     AR             AE
      electrical, chemical, and inhalation burn
      injury.
12.   Describe the pathology and management of         AR, DPC        AE
      inhalation injury, noting its relation to
      mortality, morbidity, and time course of

                                    121
      patient recovery.
13.   Explain the etiology, pathophysiology and            AR, DPC        AE
      treatment of carbon monoxide poisoning.
14.   Describe the physics and pathology of the
      electrical burn and its relation to associated
      organ injury, including:
          a. Current                                       AR, DPC        AE
         b. Entrance and exit wounds                       AR, DPC        AE
         c. Deep tissue involvement                        AR, DPC        AE
         d. Neurological injury                            AR,DPC         AE
         e. Vascular problems                              AR, DPC        AE
         f.   Rhabdomyolysis                               AR DPC         AE
15. Describe the anatomy of the hand in relation           AR, DPC        AE
    to the specialized requirements of
    management and rehabilitation of the burned
    hand .
16. Describe the indications, techniques for               AR, DPC, DSP   AE
    harvest, application, immobilization, and care
    of split- and full- thickness skin grafts in burn
    patients.
17. Explain the principles of wound contracture,
    including desirable and harmful effects of
    contracture on:
        a. Initial management of the burn victim           AR,AS, DPC     AE, DSP
         b. Closure of the burn wound                      AR, DPC        AE, DSP
         c. Rehabilitation of the burn patient             AR, AS, DPC    AE
18. Describe and explain:

         a. Compartment syndromes                          AR, DPC        AE
         b. Burn eschar contraction                        AR, DPC, AS    AE
          c. Fasciotomy and escharotomy                    AR, DPC        AE, DSP
               incisions and techniques
19.   Correctly summarize the treatment of                 AR, DPC        AE
      chemical burns to include pathology,
      sources, decontamination, and management.
20.   Describe the indications for, and basic techniques
      of, plastic and reconstructive intervention in the
      burn wound to alleviate:
          a. Scar contracture                              AR             AE
         b. Underlying joint contracture                   AR             AE



                                      122
                  c. Hypertrophic scar                             AR         AE
         21. Correctly describe the level of care and need         AR, AS     AE
             for transfer to a burn facility.

   C. Interpersonal Skills and Communication

             Principal Education Goals                           Learning     Evaluation
                                                                 Activities   Methods
         1. Clearly, accurately and succinctly present           AR           AE
            pertinent information to faculty regarding
            patients new to the service including newly
            admitted patients and patients for whom the
            service has been consulted.
         2. Clearly, accurately and respectfully                 AR, LL       AE
            communicate with patients and appropriate
            members of their families identified disease
            processes (including complications), the
            expected courses, operative findings and
            operative procedures.
         3. Maintain clear, concise, accurate and timely         AR, LL       AE
            medical records including (but not limited to)
            admission history and physical examination
            notes, consultation notes, progress notes, orders,
            operative notes and discharge summaries .

D. Professionalism

             Principal Education Goals                           Learning     Evaluation
                                                                 Activities   Methods
         1. Be honest with all individuals at all times in       LL, AR       AE
            conveying issues of patient care.
         2. Place the needs of the patient above the needs or    LL, AR       AE
            desires of self.
         3. Maintain high ethical behavior in all                LL, AR       AE
            professional activities.
         4. Demonstrate commitment to continuity of care         LL, AR       AE
            through carrying out her/his own personal
            responsibilities or through assuring that those
            responsibilities are fully and accurately
            conveyed to others acting in her/his stead.
         5. At any time while engaged in patient care, be        LL           AE
            properly and professionally groomed.
         6. Demonstrate sensitivity to issues of age, race,      LL, AR       AE
            gender and religion with patients, families and
            all members of the health care team.

                                               123
        7. At all times treat patients, families and all        LL, AR       AE
           members of the health care team with respect.
        8 Reliably be present in pre-arranged places and at     LL           AE
           pre-arranged times except when the resident is
           actively engaged in the treatment of a surgical or
           medical emergency. Under such circumstances,
           the resident should provide timely notification to
           the appropriate individual(s) of her/his inability
           to engage in the pre-arranged activity.




E.Practice-Based Learning and Improvement

            Principal Education Goals                           Learning     Evaluation
                                                                Activities   Methods
        1. Maintain a detailed log of procedures and
           operative cases in which (s)he participates
           including:
               A. Diagnosis                                     DSP, AP      AE
                B. Procedure performed                          DSP, AP      AE
                C. Postoperative course of the patient          DSP, AP      AE
                   including any complications sustained
                   and an analysis of the origins of each
                   complication.

F.Systems Based Practice

            Principal Education Goals                           Learning     Evaluation
                                                                Activities   Methods
        1. Appropriately utilize in a timely and cost
           efficient manor ancillary services including:
               A. Social work                                   AS, AR       AE
                B. Discharge planning                           AS, AR       AE
                C. Physical therapy                             AS, AR       AE
                D. Occupational therapy                         AS, AR       AE
                E. Respiratory therapy                          AS, AR       AE
                F. Nutrition services                           AS, AR       AE
        2. Summarize the financial costs, the risks and the     AR           AE
           benefits of all proposed diagnostic studies and
           therapeutic interventions.


                                              124
3. Offer sound justification for all diagnostic tests   AR, LL   AE
   (including laboratory studies) ordered by
   her/him.
4. Summarize the activities of a specialized burn
   team or unit in the overall management of the
   burn patient to include the following:

         a. Physical therapy                            AS, AR   AE
         b. Occupational therapy                        AS, AR   AE
         c. Psychological counseling                    AS, AR   AE
         d. Recreational therapy                        AS, AR   AE
         e. Burn nursing                                AS, AR   AE
         f.   Cosmetics                                 AS, AR   AE
5. Describe the indications for and
   contributions of:
   a.     Physical therapy                              AR, AS   AE
    b.        Occupational therapy                      AR, AS   AE
    c.        Physical therapy                          AR, AS   AE
    d.        Occupational therapy                      AR, AS   AE




                                       125
                         Plastic Surgery – Memorial Hermann Hospital

Transitional year residents assigned to Plastic Surgery at Memorial Hermann remain on-service
for a one month rotation. The Transitional Year resident works on a team with two faculty
members, one fellow (team leader, PGY 6 or 7) and one intern. While on the Plastic Surgery
rotation, transitional year residents will work on the inpatient service, assist in the OR with minor
procedures and work in the outpatient clinic. The transitional year resident is supervised by the
fellow and faculty. During this rotation residents will be able to demonstrate an understanding of
the nature and principles of correction and reconstruction of congenital and acquired defects of
the head, neck, trunk, and extremities. The transitional year resident should demonstrate the
ability to manage the treatment of acute, chronic, and neoplastic defects not requiring complex
reconstruction.
Call is every third or fourth night, with every third call combined with face coverage supervised by
a Plastic Fellow (PGY 6 or 7); as the Burns Service is combined with Plastic Surgery with
attending on this service covering both specialties. Adherence to the 80-hour work week is
mandated.


      Legend for Learning Activities
      AR-Attending Rounds                     CC – Core Curriculum
      DPC – Direct Patient Care               DSP – Directly Supervised Procedures
      EBM – Evidence Based Medicine           FS – Faculty Supervision
      GR – Grand Rounds                       IL – Introductory Lecture Series
      LL – Lunch & Learn                      AP – Alpha Portfolio
      AS- Ancillary Services



      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations       DSP – Directly Supervised Procedures
      MR – Morning Report              PDR – Program Director’s Review (quarterly)
      PR – Peer Review                 TYPD – Transitional Year Program Director



Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  126
A. Patient Care
          Principal Education Goals                            Learning     Evaluation
                                                               Activities   Methods
     1.   Demonstrate acquisition of a comprehensive           DPC, AR      AE
          clinical history and performance of a
          comprehensive physical examination.
     2.   Demonstrate appropriate systematic examination
          of the hand to assess motor and sensory function,
          including:
              a. Intrinsic tendon and muscle function          DPC, AR      AE
              b. Extrinsic tendon and muscle function          DPC, AR      AE
              c. Nerve function                                DPC, AR      AE
              1. Median                                        DPC, AR      AE
              2. Ulnar                                         DPC, AR      AE
             3. Radial                                         DPC, AR      AE
              d. Circulation                                   DPC, AR      AE
              e. Bones                                         DPC, AR      AE
     3.   Accurately evaluate and appropriately treat          DPC, AR      AE
          (under supervision) simple and intermediate
          abrasions anywhere on the body .
     4.   List appropriate diagnostic studies needed to
          supplement the physical examination when
          developing a treatment plan for:
              a. Surgery of the hand                           DPC, AR      AE
              b. Facial fractures                              DPC, AR      AE
              c. Congenital structural anomalies
                  1. Head and neck                             DPC, AR      AE

                  2. Hand                                      DPC, AR      AE

                  3. Trunk                                     DPC, AR      AE

     5.   Correctly perform under supervision simple           DPC, DSP     AE, DSP
          incisional biopsies of the skin and subcutaneous
          tissues of the trunk and extremities.
     6.   Correctly perform under supervision excision of      DPC, DSP     AE, DSP
          small lesions of the skin and subcutaneous tissues
          of the trunk and extremities.
     7.   Develop and present appropriate definitive           AR, DPC      AE

                                           127
      treatment plans for superficial incised and
      lacerated wounds of the neck, trunk and
      extremities.
8.    Develop and present appropriate definitive       AR, DPC    AE
      treatment plans for superficial incised and
      lacerated wounds of the neck, trunk and
      extremities.
          a. Nature of the tumor                       AR, DPC    AE
         b. Location of the lesion                     AR, DPC    AE
         c. Size of the primary tumor                  AR, DPC    AE
         d. Detection of metastatic disease            AR, DPC    AE
9.    Debride and suture major non-facial wounds       DSP, DPC   DSP, AE
      under supervision.
10.   Apply and remove dressings of the head, neck,
      hand, trunk and extremities including:
         a. Occlusive                                  DSP, DPC   DSP, AE
         b. Non-occlusive                              DSP, DPC   DSP, AE
         c. Wet to dry                                 DSP, DPC   DSP, AE
         d. Casting                                    DSP, DPC   DSP, AE
         e. Alginate                                   DSP, DPC   DSP, AE
         f.   Colloidal                                DSP, DPC   DSP, AE
11. Safely and appropriately harvest and apply split   DSP, DPC   DSP, AE
    thickness skin grafts under supervision.
12. Under appropriate supervision, perform simple,     DSP, DPC   DSP, AE
    local skin flaps for wound coverage.
13. Accurately evaluate and develop an appropriate
    treatment plan for:
        a. Hand injuries                               AR, DPC    AE
         b. Facial fractures                           AR, DPC    AE
         c. Head and neck cancer                       AR, DPC    AE
         d. Congenital anomalies                       AR, DPC    AE
         e. Breast deformities                         AR, DPC    AE
14. Correctly perform local skin flaps under           AR, DSP,   AE
    supervision.                                       DPC
15. Under appropriate supervision, the resident
    should be able to correctly reconstruct defects
    with:
        a. Random flaps                                AR, DSP,   AE, DSP


                                       128
                                                     DPC
         b. Composite flaps                          AR, DSP,   AE, DSP
                                                     DPC
16. Perform as first assistant for:
         a. Major resectional and reconstructive
            surgery of the:
            1.     Head                              DSP, DPC   AE, DSP
                2.         Neck                      DSP, DPC   AE, DSP
                3.         Breast                    DSP, DPC   AE, DSP
                4.         Trunk                     DSP, DPC   AE, DSP
                5.         Extremities               DSP, DPC   AE, DSP
         b. Complex soft tissue injury repair        DSP, DPC   AE, DSP
         c. Fractures requiring operative and        DSP, DPC   AE, DSP
            non-operative reduction
         d. Operations on hand
           1. Nerves                                 DSP, DPC   AE, DSP
              2. Tendons                             DSP, DPC   AE, DSP
              3. Bones                               DSP, DPC   AE, DSP
              4. vessels                             DSP, DPC   AE, DSP
         e. Major hand
           1. Reconstruction                         DSP, DPC   AE, DSP
              2. repair                              DSP, DPC   AE, DSP
         f.     Repair of facial trauma              DSP, DPC   AE, DSP
         g. Resection of neoplasms of the head       DSP, DPC   AE, DSP
            and neck
         h. Resection of major skin or soft tissue   DSP, DPC   AE, DSP
            neoplasm requiring complex
            reconstruction
         i. Repair of craniofacial congenital        DSP, DPC   AE, DSP
            defects
         j. Reconstruction of the breast             DSP, DPC   AE, DSP
         k. Complex wound reconstruction using
         1.      Local flaps                         DSP, DPC   AE, DSP
         2.      Regional flaps                      DSP, DPC   AE, DSP

         3.      Free microvascular flaps            DSP, DPC   AE, DSP

                                         129
     17. Under direct supervision, correctly raise muscle     DSP, DPC     AE, DSP
         and skin-muscle flaps.
     18. Demonstrate a working knowledge and safe
         application of the following procedures in the
         evaluation of patients with head and neck cancer:
             a. Nasopharyngoscopy                             DSP, DPC     AE, DSP
              b. Laryngoscopy                                 DSP, DPC     AE, DSP
              c. Esophagoscopy                                DSP, DPC     AE, DSP


B. Medical Knowledge
          Principal Education Goals                           Learning     Evaluation
                                                              Activities   Methods
     1.   List the components of a comprehensive              AR, DPC      AE
          focused history and physical examination
          pertinent to the evaluation and correction of
          congenital or acquired defects under the
          realm of plastic and reconstructive surgery.
     2.   List and describe the elements of a
          comprehensive examination of the pharynx
          (naso-, oro-, and hypo-pharynx) to include:
              a. Normal anatomy                               AR           AE
              b. Common congenital anomalies                  AR           AE
              c. Identification of neoplastic disease.        AR           AE
     3.   Describe the following for both skin and
          connective tissue:
             a. Anatomy                                       AR           AE
              b. Normal physiology                            AR           AE
              c. Normal biochemistry                          AR           AE
              d. Pathophysiology of skin neoplasms
                      1. Benign                               AR           AE
                      2. Malignant                            AR           AE
     4.   Describe the basic techniques for surgical repair
          of superficial incisions and lacerations of the
          head, neck, trunk and extremities to include the
          following considerations:
              a. Skin                                         AR           DSP, AE
              b. Subcutaneous tissues                         AR           DSP, AE
              c. Superficial muscle and fascia                AR           DSP, AE


                                           130
           d. Dressings                                   AR, AS       DSP, AE
           e. Splints                                     AR, AS, LL   DSP, AE
           f.   Suturing and knot tying                   AR, DSP      DSP, AE
5.    Describe the physiology of the following
      techniques of skin and composite tissue
      transplantation with particular regard to
      component tissue circulation:
          a. Skin grafts                                  AR, DSP      DSP, AE
      1)          Split thickness                         AR, DSP      DSP, AE
      2)        Full thickness
           b. Bone                                        AR,          AE
           c. Composite grafts                            AR           AE
           d. Skin flaps                                  AR, DSP      DSP, AE
           e. Muscle flaps                                AR, DPC      AE
           f.   Myocutaneous flaps                        AR, DPC      AE
           g. Bone flaps                                  AR, DPC      AE
           h. Myo-osseous flaps                           AR, DPC      AE
           i.   Vascularized vs. nonvascularized          AR, DPC      AE
                flaps
           j.   Neurocutaneous flaps                      AR, DPC      AE
6.    List and describe the components of:
           a. LaFort I maxillary fractures                AR, DPC      AE
           b. LaFort II maxillary fractures               AR, DPC      AE
           c. LaFort III maxillary fractures              AR, DPC      AE
7.    List the components of the nasoethmoidal            AR, DPC      AE
      disruption classification.
8.    List the components of the classification of        AR, DPC      AE
      zygomatic fractures.
9.    List the components of the classification of        AR, DPC      AE
      mandibular fractures.
10.   List the components of the classification of        AR, DPC      AE
      orbital fractures.
11.   Fully and accurately recite the TNM                 AR, DPC      AE
      classification systems for neoplasms of the skin,
      soft tissue and head and neck.
12.   Thoroughly and accurately discuss the following
      with respect to cutaneous malignancies:


                                       131
         a. Epidemiology
                 1. Basal cell carcinoma rates          AR        AE
                 2. Squamous cell carcinoma rates       AR        AE
                3. The average age of onset of basal    AR        AE
                   cell carcinoma
         b. Etiology
          1. Basal cell carcinoma                       AR        AE

          2. Squamous cell carcinoma                    AR        AE

         c. the following treatments for basal cell
             carcinoma
          1. Moh’s technique                            AR        AE

          2.Radiation therapy                           AR        AE

          3.Chemotherapy                                AR        AE

         d. Prevention using:
          1.Isotretinoin                                AR, DPC   AE

          2.Beta-carotene                               AR, DPC   AE

13. Describe the physiology, indications on the
    Plastic Surgery Service and complications for
    anesthetic agents in the following categories:
        a. Narcotics                                    AR        AE
         b. Sedatives                                   AR        AE
         c. Local anesthetics                           AR        AE
         d. General anesthetics                         AR        AE
14. Fully and accurately describe the evaluation of
    the patient with head and neck cancer including:

         a. Nature of the tumor                         AR, DPC   AE
         b. Location of the lesion                      AR, DPC   AE
         c. Size of the primary tumor                   AR, DPC   AE
         d. Detection of metastatic disease             AR, DPC   AE

15. Accurately describe the use of the reconstruction
    ladder in the definitive management of traumatic
    or excised wounds:


                                     132
         a. Skin grafts                              AR, DSP   AE, DSP
         b. Local flaps                              AR, DSP   AE, DSP
         c. Regional flaps                           AR        AE
         d. Free Microvascular flaps                 AR        AE
16. Succinctly and accurately discuss the surgical
    treatment of:
        a. Hand injuries                             AR        AE
         b. Hand tumors                              AR        AE
         c. Facial trauma                            AR        AE
         d. Soft tissue trauma                       AR        AE
         e. Boney defects                            AR        AE
         f. Neoplasms of the face (including         AR        AE
            reconstruction)
         g. Neoplasms of the skin and soft           AR        AE
            tissues requiring complex
         h. Reconstruction                           AR        AE
         i.   Congenital and acquired defects of     AR        AE
              the breast
         j.   Congenital craniofacial defects        AR        AE
17. Explain methods for performing biopsies of the
    skin and oral cavity:
        a. Incisional                                AR, DSP   AE, DSP
         b. Excisional                               AR, DSP   AE, DSP
18. Present in concise summary format currently
    accepted surgical techniques for treating the
    following:
               a. Congenital lesions
         1. Head and neck                            AR, DPC   AE
         2. Hand                                     AR, DPC   AE
         3. Trunk                                    AR, DPC   AE
                b. Craniofacial anomalies
         1. Cleft lip                                AR, DPC   AE

         2. Cleft palate                             AR, DPC   AE

                c. Breast reconstruction after       AR, DPC   AE
                   mastectomy


                                       133
                     d. Head and neck surgery
              1.   Ablative                                   AR, DPC     AE

              2.   Reconstructive                             AR, DPC     AE

              e. Aesthetic rejuvenation of the face           AR, DPC     AE
                 and body
                       .
C.Interpersonal Skills and Communication

         Principal Education Goals                           Learning     Evaluation
                                                             Activities   Methods
     1. Clearly, accurately and succinctly present           AR           AE
        pertinent information to faculty regarding
        patients new to the service including newly
        admitted patients and patients for whom the
        service has been consulted.
     2. Clearly, accurately and respectfully communicate     AR, LL       AE
        with patients and appropriate members of their
        families identified disease processes (including
        complications), the expected courses, operative
        findings and operative procedures.
     3. Maintain clear, concise, accurate and timely         AR, LL       AE
        medical records including (but not limited to)
        admission history and physical examination
        notes, consultation notes, progress notes, orders,
        operative notes and discharge summaries.

D. Professionalism

         Principal Education Goals                           Learning     Evaluation
                                                             Activities   Methods
     1. Be honest with all individuals at all times in       LL, AR       AE
        conveying issues of patient care.
     2. Place the needs of the patient above the needs or    LL, AR       AE
        desires of self.
     3. Maintain high ethical behavior in all professional   LL, AR       AE
        activities.
     4. Demonstrate commitment to continuity of care         LL, AR       AE
        through carrying out her/his own personal
        responsibilities or through assuring that those
        responsibilities are fully and accurately conveyed
        to others acting in her/his stead.
     5. At any time while engaged in patient care, be        LL           AE
        properly and professionally groomed.

                                           134
      6. Demonstrate sensitivity to issues of age, race,         LL, AR       AE
         gender and religion with patients, families and all
         members of the health care team.
      7. At all times treat patients, families and all           LL, AR       AE
         members of the health care team with respect.
      8. Reliably be present in pre-arranged places and at       IL, LL       AE
         pre-arranged times except when the resident is
         actively engaged in the treatment of a surgical or
         medical emergency. Under such circumstances,
         the resident should provide timely notification to
         the appropriate individual(s) of her/his inability
         to engage in the pre-arranged activity.



E. Practice-Based Learning and Improvement

           Principal Education Goals                             Learning     Evaluation
                                                                 Activities   Methods
      1. Maintain a detailed log of procedures and
         operative cases in which (s)he participates
         including:
             A. Diagnosis                                        DSP, AP      AE, TYPD
               B. Procedure performed                            DSP, AP      AE, TYPD
               C. Postoperative course of the patient            DSP, AP      AE, TYPD
                   including any complications sustained
                   and an analysis of the origins of each
                   complication.
      2.   Maintain a portfolio of rotation related literature   DSP, AP      AE
           searches.
      3.   Maintain a portfolio of rotation related formal       AP           AE, TYPD
           presentations including presentation of
           complications (Morbidity and Mortality
           Conference).

F.   Systems Based Practice

           Principal Education Goals                             Learning     Evaluation
                                                                 Activities   Methods
      1. Appropriately utilize in a timely and cost efficient
         manor ancillary services including:
            A. Social work                                       AS, AR       AE
               B. Discharge planning                             AS, AR       AE


                                              135
        C. Physical therapy                             AS, AR   AE
        D. Occupational therapy                         AS, AR   AE
        E. Respiratory therapy                          AS, AR   AE
        F. Nutrition services                           AS, AR   AE
2. Summarize the financial costs, the risks and the     AR       AE
   benefits of all proposed diagnostic studies and
   therapeutic interventions.
3. Offer sound justification for all diagnostic tests   AR, IL   AE
   (including laboratory studies) ordered by her/him.




                                     136
     Surgical Immunology and Transplantation Service – Memorial Hermann Hospital

The Memorial Hermann Hospital Surgical Immunology and Organ Transplantation rotation is a
one month rotation to which Transitional Year Residents are assigned. Transitional Year
Residents are on a team with four transplant surgeons, three transplant nephrologists, four
transplant fellows, one transplant PGY 1 and two or three Internal Medicine Nephrology fellows.
The Transitional Year Resident is supervised by the fellow and faculty. During this rotation the
Transitional Year resident should be able to demonstrate a general understanding of general
immunological principles and their application to surgical practice. The resident should also be
able to demonstrate an understanding of the principles of care for patients with abnormal
immune function who are undergoing general surgery procedures. Additionally, the resident
should be able to demonstrate an understanding of clinical transplantation. He/she should be
able to interpret the guidelines for preparing patients for organ transplantation.

Call is every third night and is supervised by the in-house fellow on call with faculty from home.
Adherence to the 80 hour work week is mandated.


      Legend for Learning Activities
      AR-Attending Rounds                     CC – Core Curriculum
      DPC – Direct Patient Care               DSP – Directly Supervised Procedures
      EBM – Evidence Based Medicine           FS – Faculty Supervision
      GR – Grand Rounds                       IL – Introductory Lecture Series
      LL – Lunch & Learn



      Legend for Evaluation of Methods for Residents
      AE – Attending Evaluations       DSP – Directly Supervised Procedures
      MR – Morning Report              PDR – Program Director’s Review (quarterly)
      PR – Peer Review
      TYPD – Transitional Year Program Director



Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column
of the table lists the goal, the third column lists the most relevant learning activities for that goal,
and the fourth column indicates the correlating evaluation methods for that goal.




                                                  137
A. Patient Care
          Principal Education Goals                           Learning       Evaluation
                                                              Activities     Methods
     1. Participate in the perioperative management of        AR, DPC        AE
        immunosuppressive agents in chronically-
        medicated patients undergoing general surgery.
     2. Recognize and treat wound infections and other        AR, DPC        AE
        complex disorders in chronically
        immunosuppressed patients undergoing elective
        and emergent surgery.
     3. Monitor drug levels and side effects of               AR, DPC        AE
        immunosuppressants.


B. Medical Knowledge
          Principal Education Goals                            Learning      Evaluation
                                                               Activities    Methods
     1.    Describe the basic concepts of the human
           immune system including
              a. cells involved in host defense                AR, DPC, GR   AE
                b. central roles of lymphocytes and            AR, DPC, GR   AE
                    macrophages
                c. their derivation from pluripotent stem      AR, DPC, GR   AE
                    cells
     2.    Summarize the major activities of the               AR, DPC, GR   AE
           macrophage, its products of secretion, and its
           role as the antigen-presenting cell (APC)
     3.    Describe the ontogeny, function, and role in        AR, DPC, GR   AE
           cellular immunity and graft rejection of the T-
           lymphocyte; demonstrate understanding of the T-
           cell receptor and its interaction with the human
           leukocyte antigen (HLA) complex
     4.    Summarize the events in T-cell activation,          AR, DPC, GR   AE
           including the roles of CD4+ and CD8+ cells and
           the release of involved interleukins.
     5.    Explain the development, differentiation, and       AR, DPC, MR   AE
           function of B-lymphocytes in the formation of
           antibodies; outline and describe the functional
           anatomy of an immunoglobulin molecule.
     6.    Describe the immune functions of the spleen,        AR, DPC, MR, AE
           liver, thymus, and bone marrow and summarize        GR
           the impact of their manipulation on the immune
           system.
     7.    Describe the resident flora, mechanical barriers
           local hormones, and chemicals of the epithelium


                                           138
      in the following tracts involved in the body’s
      defenses against infection:
                  a. gastrointestinal                      AR, DPC, MR   AE
                b. respiratory                             AR, DPC, MR   AE
                c. genitourinary                           AR, DPC, MR   AE
8.    Describe the body’s response to infection when:
          a. there has been no prior antigenic             AR, DPC       AE
               contact
          b. there has been prior contact to               AR, DPC       AE
               passive and active immunization
          c. there has been prior contact to T-cell        AR,DPC        AE
               memory activation
9.    Explain the therapeutic and prophylactic roles of    AR, DPC, MR   AE
      intravenous immunoglobulin and viral vaccines.
10.   Distinguish between several known congenital         AR, DPC, MR   AE
      and acquired immunodeficiency states, including
      sepsis and severe burns.
11.   Describe tests of cellular immune integrity,         AR, DPC       AE
      including skin and laboratory tests of lymphocyte
      function.
12.   Define the anatomic and biologic terms               AR, DPC       AE
      associated with organ transplantation, donor and
      recipient relationships, and grafting between
      species.
13.   Discuss the role of tissue typing in the
      identification and preparation of patients for
      organ transplantation to include
          a. natural, pre-formed antibodies                AR, DPC       AE
          b. acquired antibodies                           AR, DPC       AE
           c. the role of panel reactive antibody          AR, DPC       AE
                (PRA) (sensitization)
           d. the effect of tissue typing                  AR, DPC       AE
                compatibility on graft survival
14.   Define the criteria for organ and tissue donation;   AR, DPC, MR   AE
      apply these criteria to critically-ill patients.
15.   Explain the clinical definition of brain death,      AR, DPC, LL   AE, TYPD
      including a discussion of the available laboratory
      and radiologic studies to support the clinical
      criteria.
16.   Outline the development of organ preservation        AR, DPC       AE
      solutions and techniques and describe the
      currently practiced methods for handling and
      storing vascularized organs.
17.   Describe the mechanism of action, dosing

                                       139
          schedule, and side effects of the following
          immunosuppressive drugs:
              a. Azathiroprine                             AR, DPC     AE
              b. Prednisone                                AR, DPC     AE
              c. Antilymphocyte globulins                  AR, DPC     AE
              d. Cyclosporine                              AR, DPC     AE
              e. Anti-CD3 monoclonal antibody              AR, DPC     AE
              f. Tacrolimus (FK506); Rapamycin             AR, DPC     AE
                 (Sirolimus)
              g. Simulect and Zenapax                      AR, DPC     AE
              h. FTY 720                                   AR, DPC     AE
              i.   Campath (AntiCD52)                      AR, DPC     AE
     18. Analyze the short – and long – term risks of
         chronic immunosuppression including:
             a. opportunistic infections                   AR, DPC     AE
              b. cardiovascular problems                   AR, DPC     AE
              c. autoimmune diseases                       AR, DPC     AE
              d. lymphoproliferative disease               AR, DPC     AE
              e. rejection                                 AR, DPC     AE

C.Interpersonal Skills and Communication

         Principal Education Goals                        Learning     Evaluation
                                                          Activities   Methods
     1. Be able to clearly, accurately and succinctly     AR, MR       AE
        present pertinent information to faculty
        regarding patients new to the service including
        newly admitted patients for whom the service
        has been consulted.
     2. Clearly, accurately and respectfully              AR           AE
        communicate with nurses and other hospital
        employees.
     3. Clearly, accurately and respectfully              AR, DPC      AE
        communicate with patients and appropriate
        members of their families identified disease
        processes (including complications), the
        expected courses, operative findings and
        operative procedures.

                                           140
     4. Maintain clear, concise, accurate and timely      GR, AR       AE
        medical records including (but not limited to)
        admission history and physical examination
        notes, consultation notes, progress notes,
        orders, operative notes and discharge
        summaries.
D. Professionalism

         Principal Education Goals                        Learning     Evaluation
                                                          Activities   Methods
     1. Be honest with all individuals at all times in    AR, MR, LL   AE, TYPD
        conveying issues of patient care.
     2. Maintain high ethical behavior in all             AR, MR, LL   AE, TYPD
        professional activities
     3. Demonstrate commitment to continuity of care      AR, MR, LL   AE, TYPD
        through carrying out her/his own personal
        responsibilities or through assuring that those
        responsibilities are fully and accurately
        conveyed to others acting in her/his stead.
     4. Demonstrate commitment to continuity of care      AR, MR, LL   AE, TYPD
        through carrying out her/his own personal
        responsibilities or through assuring that those
        responsibilities are fully and accurately
        conveyed to others acting in her/his stead.
     5. Demonstrate sensitivity to issues of age, race,   AR, MR, LL   AE, TYPD
        gender and religion with patients, families and
        all members of the health care team.
     6. At all times treat patients, families and all     AR, MR, LL   AE, TYPD
        members of the health care team with respect.
     7. Reliably be present in pre-arranged places and    AR, MR, LL   AE, TYPD
        at pre-arranged times except when the resident
        is actively engaged in the treatment of a
        surgical or medical emergency. Under such
        circumstances, the resident should provide
        timely notification to the appropriate
        individual(s) of her/his inability to engage in
        the pre-arranged activity.




                                          141
E. Practice-Based Learning and Improvement

         Principal Education Goals                         Learning      Evaluation
                                                           Activities    Methods
     1. Maintain a detailed log of procedures and
        operative cases in which (s)he participates
        including:
             a.   Diagnosis                                DSP, AP       AE, TYPD
             b. Procedure performed                        DSP, AP       AE,TYPD
             c. Postoperative course of the patient        DSP, AP       AE, TYPD
                including any complications sustained
                and an analysis of the origin(s) of each
                complication
     2. Maintain a portfolio of rotation relation          AP            AE, TYPD
        literature searches.
     3. Maintain a portfolio of rotation related formal    AP            AE, TYPD
        presentations including presentation of
        complications (Morbidity and Mortality
        Conference)

F. Systems Based Practice

         Principal Education Goals                         Learning      Evaluation
                                                           Activities    Methods
     1. Be able to appropriately utilize in a timely and
        cost efficient manor ancillary services
        including:
             a.   Social Work                              AR, DPC, MR   AE
             b. Discharge Planning                         AR, DPC, MR   AE
             c. Physical Therapy                           AR, DPC, MR   AE
             d. Occupational therapy                       AR, DPC, MR   AE
             e. Respiratory Therapy                        AR, DPC, MR   AE
             f.   Nutrition Services                       AR, DPC, MR   AE
             g. Pharmacists                                AR, DPC, MR   AE
             h. Physician Extenders including              AR, DPC, MR   AE
                Physicians’ Assistants and Nurse
                Practitioners
     2. Summarize the financial costs, the risks and the AR, MR, DPC     AE

                                          142
    benefits of all proposed diagnostic studies and
    therapeutic interventions.
3. Offer sound justification for all diagnostic tests   AR, MR   AE
   (including laboratory studies) ordered by
   her/him.




                                      143
                                                  Neurosurgery

Transitional Year Residents assigned to the Neurosurgery Service do a one month block rotation. The Neurosurgery
Service is supported by 15 experienced advanced practice providers, Physician Assistants and Nurse Practitioners,
who assist in surgery, take in-house call 24 hours a day, work in the clinics, and perform bedside procedures. Two
advanced practice providers are in-house each night, one covering the ICU and the other the ER and wards. This
staff is a major advantage for the Neurosurgery Program, allowing Transitional Year residents to focus on activities
with educational value. The 80 hour work week is mandated . In addition to the advanced practice providers, there is
a resident in-house each night, backed up by a chief or senior resident from home.

The program is sponsored by the University of Texas Medical School at Houston, and clinical training will occur at
the adjacent Mischer Neuroscience Institute of the Memorial Hermann Hospital (the primary teaching venue for the
medical school).


  Legend for Learning Activities
  AR – Attending Rounds          EBM-Evidence Based Medicine                  MR – Morning Report
                                 FS – Faculty Supervision                     NRMC – NeuroRadiology
  CC-Core Curriculum             GR – Grand Rounds                            Multidisciplinary Conference
  DPC – Direct Patient Care      IL-Introductory Lecture Series
  DSP – Directly Supervised      LL-Lunch and Learn
    Procedures
  JC-Journal Club

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                  PDR–Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures        TYPD-TY Program Director
  MR – Morning Report


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.




A. Patient Care

                                                                              Learning               Evaluation
           Principal Educational Goals
                                                                              Activities             Methods
 1.        Perform and document a comprehensive neurosurgery                  AR, DPC                AE
           history and physical examination
 2.        Complete the initial evaluation of outpatient and emergent         AR, DPC                AE
           neurosurgical patients
 3.        Select and interpret appropriate investigations (laboratory        AR, DPC                AE
           studies and imaging)


                                                       144
4.    Perform initial resuscitation of patients who are critically ill   AR, DPC       AE
      with neurosurgical problems.
5.    Assist in major surgical procedures and perform those              DSP, DPC      AE, DSP
      portions of such procedures (under supervision) that are
      appropriate for their level of training.
6.    Perform selected surgical procedures under direct                  DSP, DPC      AE, DSP
      supervision.
      Specific Sills Include:                                                          AE

7.    ER/ICU                                                                           AE
      assess and participate in the treatment of patients with
      injury to:
          a.   Head/face                                                 DPC, AR       AE

          b. Brain and spinal cord                                       DPC, AR       AE

          c.   Spine                                                     DPC, AR       AE

          d. Peripheral nerve/extremity                                  DPC, AR       AE

          e. Multiple systems                                            DPC, AR       AE

8.    assess and participate in the treatment of patients with:                        AE

          a. Increased ICP                                               DPC, AR       AE

          b. Ischemic/hemorrhagic cerebrovascular disease                DPC, AR       AE

          c.   Brain tumors                                              DPC, AR       AE

          d. Degenerative spinal disorders                               DPC, AR       AE

          e. Spinal cord or cauda equine compression                     DPC, AR       AE

          f.   Actue or chronic seizures                                 DPC, AR       AE

          g. Cardiac, pulmonary, renal or electrolyte disorders          DPC, AR       AE

9.    learn to work effectively as a member of a team,                   DPC, LL, AR   AE
      communicate effectively with consultants and ancillary
      services
      WARD
10.   Make regular independent ward rounds                               DPC, AR       AE

11.   demonstrate knowledge of the patients and their problems           DPC, AR       AE

12.   Be able to recognize and treat complications of disease            DPC, AR       AE
      and procedures
13.   Understand the social aspects of care and discharge                DPC, AR       AE
      planning, work with care coordinators and patient liaisons

      Clinic/Ambulatory setting


                                                   145
14.   Take a thorough history and perform an accurate               DPC, AR       AE
      neurological examination
15.   Form a meaningful differential diagnosis                      DPC, AR       AE

16.   Demonstrate knowledge of non-operative and operative          DPC, AR       AE
      management of patient problems
17.   Learn to communicate effectively with patients and families   DPC, AR, LL   AE, TYPD

18.   Interpret imaging studies                                     AR, NRMC      AE

      Conferences:
19.   Present cases in an organized and articulate manner on        CC, AR        AE
      rounds and conferences
      Procedures
20.   lumbar puncture                                               DSP           AE, DSP

21.   ventriculostomy                                               DSP           AE, DSP

22.   ICP monitor                                                   DSP           AE, DSP

23.   skeletal traction- tongs, halo                                DSP           AE, DSP

      Patient set-up: OR
24.   patient positioning for cranial, spinal, peripheral nerve     CC, AR        AE
      procedures
25.   head rests                                                    CC, AR        AE

26.   head fixation devices                                         CC, AR        AE

      Surgical assistance
29.   handles tissues appropriately                                 DSP           AE, DSP

30.   stop simple bleeding                                          DSP, DPC      AE, DSP

31.   takes direction well                                          DSP           AE, DSP

32.   facility in anticipating surgical maneuvers                   DSP           AE, DSP

33.   ability to perform as a team member                           DSP           AE, DSP

      Surgical procedures:

34.   VP shunt                                                      DSP           AE, DSP

35.   Burrholes                                                     DSP           AE, DSP




                                                 146
 36.                                                               DSP               AE, DSP
        Craniotomy for epidural/subdural hematoma

 37.    Opening of simple craniotomies or craniectomies            DSP               AE, DSP

 38.    Elevation of depressed skull fracture                      DSP               AE, DSP

 39.    Closure of dura mater in head and spine                    DSP               AE, DSP

 40.    Incision planning for spinal surgery                       DSP               AE, DSP

 41.    Exposure of spinal lamina, dural tube, and nerve root      DSP               AE, DSP

 42.    Removal of cervical discs with anterior fusion             DSP               AE, DSP

 43.    Lumbar laminectomies and removal of lumbar                 DSP               AE, DSP
        intervertebral discs




B. Medical Knowledge

                                                                   Learning          Evaluation
        Principal Educational Goals
                                                                   Activities        Methods
 1.     Start the first year of the UT Neurosurgery Core
                                                                   AR, DPC           AE
        Curriculum
 2.     Generate an appropriate differential diagnosis             AR, DPC           AE
 3.     Demonstrate knowledge of the anatomy and physiology
                                                                   AR, DPC, CC, GR   AE
        relevant to clinical neurosurgery
 4.     Describe common neurosurgical operations.                  AR, DPC           AE
 5.     Suggested Text: Youmans, Neurological Surgery.             AR, DPC           AE

C. Interpersonal Skills and Communication

                                                                   Learning          Evaluation
        Principal Educational Goals
                                                                   Activities        Methods
 1.     Develop excellent interpersonal and communication skills
        (verbal and written).                                      AR, DPC, LL       AE, TYPD

 2.     Demonstrate the ability to accurately document findings
                                                                   AR. DPC           AE
        and a plan of treatment
 3      Communications: patients and family
            A. develop the ability to communicate with patients
                and their families in understandable terms,        AR, DPC, LL       AE
                providing basic information and the plan of
                treatment


                                                  147
            B.   respect each patient’s right to privacy
            C. develop sensitivity to ethnic, cultural, and
              socioeconomic backgrounds when working with
              each patient, their families, and co-workers
 4      Communications: other health care personnel
           A. be able to work in a co-operative manner with
              other health care personnel, being sensitive to
              their roles and abilities, providing prompt,
              courteous, and respectful communication
           B. be able to give and receive advice in an objective,
                                                                      LL, AR       TYPD
              mature manner
           C. answer pages promptly
           D. complete medical records, dictations promptly
              and accurate




D. Professionalism

                                                                      Learning     Evaluation
        Principal Educational Goals
                                                                      Activities   Methods
 1.     Be honest, reliable, team-oriented and respectful in
                                                                      AR, DPC      AE
        interactions with patients, consultants, neurosurgical team
 2      Read TK Kushner & DC Thomas, Ward Ethics: Dilemmas
        for Medical Students and Doctors in Training, Cambridge,
                                                                      AR, CC       AE
        2001. Participate in Grand Rounds discussions involving
        ethics and professionalism

E.Practice-Based Learning and Improvement

                                                                      Learning     Evaluation
       Principal Educational Goals
                                                                      Activities   Methods
 1.    Demonstrate critical appraisal skills when using the medical
                                                                      AR, CC       AE
       literature.
 2.    Present literature review at Grand Rounds, “evidence
       review and journal club.” Receive written critique from the    GR           AE
       program director or chairman

F. Systems-Based Practice

                                                                      Learning     Evaluation
        Principal Educational Goals
                                                                      Activities   Methods
 1.     Demonstrate an awareness of the variety of systems
        within which health care is provided.                         AR, LL       AE, TYPD




                                                 148
                  GENERAL INPATIENT PEDIATRIC ROTATION
Residents assigned to the Memorial Hermann Children’s Hospital (“MHCH”) and the LBJ Hospital
(“LBJ”) general inpatient rotation work in teams of one senior resident (PGY-3/4), two to four
residents (PGY-1/2) and two to three medical students. The senior resident functions as the team
leader and is responsible for the daily management of the team and the patients in the team’s care.
One faculty attending is assigned to each team and participates in direct patient care and as a
consultant to the team.

The general inpatient pediatric rotation is a one-month block at LBJ in which low risk nursery,
outpatient pediatrics and inpatient pediatrics are combined as a primary care rotation.

All ward teams care for patients with both general medical and subspecialty problems and surgical
problems. Resident teams develop diagnostic and therapeutic management plans in collaboration
with the attending physician of record through daily evaluation and discussion. Call is every fourth
night, the post-call team leaves the hospital at 1:00 p.m., and there is one day off during the week.
There is always one senior resident and one or two PGY-1/2 residents on call. Adherence to the 80-
hour work week is mandated.

The inpatient experience at LBJ is gained through a vertically integrated three month block which
includes general pediatrics and outpatient pediatrics as well as normal/term newborn. There are two
teams at LBJ which are composed of one senior resident and three PGY-1 residents. Each team
admits new patients and takes new term infants every other day. PGY-1 residents admit on average
two to four new term newborns per day. The senior resident functions as the team leader and is
responsible for the daily management of the team and the patients in the team’s care. A faculty
attending from The University of Texas Medical School at Houston Division of Community and
General Pediatrics is assigned to each team and participates in direct patient care and as a
consultant to the team.

Patients seen on the general inpatient rotation include patients admitted from University of Texas
clinics or the ER, patients referred to faculty physicians, private patients of faculty physicians, and
patients of community practitioners.

  Legend for Learning Activities
  AR – Attending Rounds                 HPDO – History & Physical          NC – Noon Conferences
  DPC – Direct Patient Care             Directly Observed                  PALS – Pediatric Advanced
  CAT – Critically Appraised            JC – Journal Club                  Life Support
  Topics                                LL – Lunch & Learn                 RC – Research Conference
  EBM – Evidence-Based                  MR – Morning Report                SS – Senior Seminar
  Medicine Course                       M&M – Morbidity and Mortality      SL – Subspecialty
  E/C – Ethics/Communication            Conference                         Lectures
  Conferences                           MDR – Multidisciplinary
  GR – Grand Rounds                     Rounds




                                                 149
  Legend for Evaluation Methods for Residents
  AE – Attending Evaluations                                   PDR – Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures                         FS – Faculty Supervision & Feedback
  MR – Morning Report                                          TYPD – Transitional Year Program Director
  PR – Peer Review



Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.



A. Patient Care

GOAL: Continuum of Care

       Manage the continuum of care for children with acute illness/injury from initial
presentation (i.e., office, clinic, emergency room) through acute hospital care (including
transfer in and out of PICU), discharge, home health services and office follow-up care.

        Principal Educational Objectives – Continuum of                      Learning              Evaluation
        Care                                                                 Activities            Methods
  1.    Review past medical history, family history,                         AR, DPC, FS,          AE, FS, MR,
        immunizations and development.                                       HPDO                  DSP, TYPD
  2.    Provide acute patient care, diagnosis, stabilization and             AR, DPC, CAT,         AE, FS, MR,
        management of a variety of acute illnesses.                          FS, GR, JC,           DSP
                                                                             MR, NC, SL,
  3.    Coordinate subspecialist consults for patients.                      AR, DPC, FS,          AE, FS, MR,
                                                                             MR
  4.    Participate in (PGY-1) decision-making regarding                     AR, DPC, FS,          AE, FS, MR,
        transfer to PICU.                                                    MR
  5.    Interact with the surgical team and manage patients in               AR, DPC, FS,          AE, FS, MR,
        the pre-operative and post-operative environments.                   MR
  6.    Demonstrate the skills necessary for assessing and                   AR, DPC, FS,          AE, FS, MR,
        managing pain and conscious sedation.                                PALS                  DPS
  7.    Communicate with a given family and child the impact of              AR, DPC, E/C,         AE, FS,
        each phase of care on the final health care outcome.                 FS
        Assess the psychosocial impact of illness on the child
        and family and the financial burden to the family and the
        health care system.
  8.    Provide appropriate discharge planning and follow-up                 AR, DPC, MDR          AE, FS,
        care for patients with chronic illnesses.




                                                      150
GOAL: Common Signs and Symptoms of General Childhood Diseases

       Identify and manage common signs and symptoms of childhood illnesses cared for in
the inpatient setting.

      Principal Educational Objectives – Common Signs              Learning        Evaluation
      and Symptoms                                                 Activities      Methods
 1.   Perform a directed history and physical examination          AR, DPC, MR,    AE, FS, DSP
      including height, weight and FOC percentiles.                FS              (PGY-1),
 2.   Perform an in-depth interview assessing behavioral,          AR, DPC, MR,    AE, FS, DSP
      psychosocial, environmental and family unit correlates       FS              (PGY-1)
      of disease.
 3.   Evaluate and manage the following common signs and           AR, DPC, CAT,   AE, FS,
      symptoms that present in the inpatient setting:              GR, JC, MR,
                                                                   NC, SL
 a.   General – failure to thrive, weight loss, fever without      AR, DPC, CAT,   AE, FS,
      localizing signs, constitutional symptoms, and acute life-   GR, JC, MR,
      threatening event (ALTE)                                     NC, SL
 b.   Cardiovascular – hypotension, hypertension, rhythm           AR, DPC, CAT,   AE, FS,
      disturbance, syncope, heart murmur and shock                 GR, JC, MR,
                                                                   NC, SL
 c.   Dermatologic – rashes, petechiae, purpura,                   AR, DPC, CAT,   AE, FS,
      ecchymoses, urticaria and edema                              GR, JC, MR,
                                                                   NC, SL
 d.   EENT - trauma, conjunctival injection, acute visual          AR, DPC, CAT,   AE, FS,
      changes, edema, epistaxis                                    GR, JC, MR,
                                                                   NC, SL
 e.   Endocrine – polydipsia, polyuria                             AR, DPC, CAT,   AE, FS,
                                                                   GR, JC, MR,
                                                                   NC, SL
 f.   GI/nutrition/fluids – diarrhea, vomiting, dehydration,       AR, DPC, CAT,   AE, FS,
      inadequate intake, dysphagia, regurgitation, abdominal       GR, JC, MR,
      pain, abdominal masses, hematemesis, rectal bleeding,        NC, SL
      jaundice and ascites
 g.   GU/Renal – hematuria, edema, decreased urine output,         AR, DPC, CAT,   AE, FS,
      scrotal masses and dysuria                                   GR, JC, MR,
                                                                   NC, SL
 h.   Gynecologic – genital trauma, sexual assault, pelvic         AR, DPC, CAT,   AE, FS,
      pain and abnormal vaginal bleeding                           GR, JC, MR,
                                                                   NC, SL
 i.   Hematologic/Oncologic – pallor, abnormal bleeding,           AR, DPC, CAT,   AE, FS,
      lymphadenopathy, hepatosplenomegaly and masses               GR, JC, MR,
                                                                   NC, SL
 j.   Musculoskeletal – bone and soft tissue trauma, limp,         AR, DPC, CAT,   AE, FS,
      arthritis/arthralgia and limb pain                           GR, JC, MR,
                                                                   NC, SL
 k.   Neurologic – seizure, headache, delirium, lethargy,          AR, DPC, CAT,   AE, FS,
      weakness, ataxia, coma, head trauma, vertigo and             GR, JC, MR,
      irritability                                                 NC, SL


                                              151
 l.   Psychiatric/Psychosocial – acute psychosis, suicide         AR, DPC, CAT,   AE, FS,
      attempt, depression, conversion symptoms, child             GR, JC, MR,
      abuse/neglect and eating disorders                          NC, SL
 m.   Respiratory – increased work of breathing, cyanosis,        AR, DPC, CAT,   AE, FS,
      apnea, dyspnea, tachypnea, wheezing, stridor,               GR, JC, MR,
      inadequate respiratory effort, cough, hemoptysis, chest     NC, SL
      pain and respiratory failure

GOAL: Common Conditions

      Recognize and manage common childhood conditions in the inpatient setting.

      Principal Educational Objectives – Common                   Learning        Evaluation
      Conditions                                                  Activities      Methods
 1.   Describe the criteria for admission to inpatient services   AR, MR          AE, FS, , MR
      and transfer to the PICU.
 2.   Develop and implement a plan for the inpatient              AR, MR          AE, FS, MR
      diagnosis and treatment of common childhood
      conditions.
 3.   Describe when it is appropriate to refer a patient to a     AR, MR          AE, FS, MR
      pediatric consultant.
 4.   Describe the criteria for discharge from inpatient          AR, MR, MDR     AE, FS
      services.
 5.   Develop and implement discharge plans including             AR, MR, MDR     AE, FS
      arrangements for appropriate follow-up care and patient
      education.
      Common Conditions:                                          AR, MR, MDR     AE, FS

 a.   General – failure to thrive, fever of unknown origin and    AR, MR, MDR     AE, FS
      burns
 b.   Allergy/Immunology – acute exacerbation of chronic          AR, MR, MDR     AE, FS
      asthma, acute and significant drug allergies/reactions
 c.   Cardiovascular – congestive heart failure, SVT,             AR, MR, MDR     AE, FS
      arrhythmias, Kawasaki disease and cardiomyopathy
 d.   Endocrine – diabetes (including DKA), electrolyte           AR, MR, MDR     AE, FS
      disturbances secondary to underlying endocrine
      disease
 e.   GI/Nutritional/Fluids – gastroenteritis, dehydration,       AR, MR, MDR     AE, FS
      electrolyte abnormalities, acidosis, gastroesophageal
      reflux, pyloric stenosis and liver disease
 f.   GU/Renal – UTI/pyelonephritis, nephrotic syndrome,          AR, MR, MDR     AE, FS
      glomerulonephritis, electrolyte and acid-base
      disturbances
 g.   Hematology/Oncology – neutropenia, sickle cell crisis       AR, MR, MDR     AE, FS
      and other complications, thrombocytopenia, and
      common malignancies
 h.   Infectious Disease – cellulitis, periorbital and orbital    AR, MR, MDR     AE, FS
      cellulitis, cervical adenitis, pneumonia (viral or
      bacterial), laryngotracheobronchitis, meningitis


                                             152
       (bacterial or viral), encephalitis, sepsis/bacteremia
       (including newborns), osteomyelitis, pelvic inflammatory
       disease, septic arthritis, shunt or line infection,
       infections in AIDS patients, and late presentation of
       congenital infections
 i.    Pharmacology/Toxicology – common drug poisoning            AR, MR, MDR    AE, FS
       or overdose
 j.    Neurology – seizures, severely handicapped children        AR, MR, MDR    AE, FS
       with acute medical conditions, developmental delay,
       closed head injury and acute neurological conditions
 k.    Respiratory – apnea, airway obstruction, croup, cystic     AR, MR, MDR    AE, FS
       fibrosis, aspiration and chronic lung disease
 l.    Rheumatologic – HSP, SLE                                   AR, MR, MDR    AE, FS

 m.    Surgery – pre- and post-op evaluation of common            AR, MR, MDR    AE, FS
       surgical patients, fractures, tonsillectomy and
       adenoidectomy

GOAL: Management and Decision-Making

       Develop a logical and appropriate clinical approach to the care of hospitalized
children.

       Principal Educational Objectives – Management and          Learning       Evaluation
       Decision-Making                                            Activities     Methods
 1.    Utilize principles of decision-making and problem          AR, MR, DPC    AE, FS,
       solving skills in the care of hospitalized children.
 2.    Identify and prioritize patients’ medical problems and     AR, MR, DPC    AE, FS,
       generate appropriate differential diagnoses.

GOAL: Patient Support and Advocacy

      Provide sensitive support to patients and families of children with acute illness and
arrange for on-going support and/or preventive services at discharge.

       Principal Educational Objectives – Patient Support         Learning       Evaluation
       and Advocacy                                               Activities     Methods
 1.    Discuss issues such as growth and nutrition,               AR, MR, DPC,   AE, FS,
       developmental stimulation and schooling during             MDR
       extended hospitalizations with patients and their
       families.
 2.    Recognize problems and/or risk factors in the child or     AR, MR, DPC    AE, FS,
       family even outside the scope of the admission (e.g.,
       immunizations, social risks, developmental delay) and
       appropriately intervene or refer.
 3.    Demonstrate the skills necessary for accessing and         AR, MR, DPC,   DSP
       managing pain.                                             PALS
 4.    Treat families in a non-judgmental, culturally sensitive   AR, MR, DPC,   AE, FS,
       manner.                                                    E/C, LL        TYPD


                                               153
B. Medical Knowledge

GOAL: Common Signs and Symptoms

        Develop a differential diagnosis; formulate an appropriate work-up with diagnostic
tests to establish a diagnosis. Develop appropriate treatment plan for the diagnosis.

       Principal Educational Objectives – Common Signs           Learning      Evaluation
       and Symptoms                                              Activities    Methods
 1.    Create a differential diagnosis with age appropriate      MR, AR, DPC   AE, FS,
       considerations.
 2.    Discuss indications for hospitalization and formulate a   MR, DPC, AR   AE, FS
       plan for inpatient diagnosis and management.
 3.    Discuss the pathophysiological basis for the disease or   MR, AR, DPC   AE, FS
       injury.
       Common Signs and Symptoms:                                MR, AR, DPC   AE, FS

 a.    General – failure to thrive, weight loss, fever without   MR, AR, DPC   AE, FS
       localizing signs, and constitutional symptoms
 b.    Cardiovascular – hypotension, hypertension, rhythm        MR, AR, DPC   AE, FS
       disturbance, syncope, heart murmur and shock
 c.    Dermatologic – rashes, petechiae, purpura,                MR, AR, DPC   AE, FS
       ecchymoses, urticaria and edema
 d.    EENT: trauma, conjunctival injection, acute visual        MR, AR, DPC   AE, FS
       changes, edema, epistaxis
 e.    Endocrine – polydipsia, polyuria                          MR, AR, DPC   AE, FS

 f.    GI/nutrition/fluids – diarrhea, vomiting, dehydration,    MR, AR, DPC   AE, FS
       inadequate intake, dysphagia, regurgitation, abdominal
       pain, abdominal masses, hematemesis, rectal bleeding,
       jaundice and ascites
 g.    GU/Renal – hematuria, edema, decreased urine output,      MR, AR, DPC   AE, FS
       scrotal masses and dysuria
 h.    Gynecologic – genital trauma, sexual assault, pelvic      MR, AR, DPC   AE, FS
       pain and abnormal vaginal bleeding
 i.    Hematologic/Oncologic – pallor, abnormal bleeding,        MR, AR, DPC   AE, FS
       lymphadenopathy, hepatosplenomegaly and masses
 j.    Musculoskeletal – bone and soft tissue trauma, limp,      MR, AR, DPC   AE, FS
       arthritis/arthralgia and limb pain
 k.    Neurologic – seizure, headache, delirium, lethargy,       MR, AR, DPC   AE, FS
       weakness, ataxia, coma, head trauma, vertigo and
       irritability
 l.    Psychiatric/Psychosocial – acute psychosis, suicide       MR, AR, DPC   AE, FS
       attempt, depression, conversion symptoms, child
       abuse/neglect and eating disorders
 m.    Respiratory – increased work of breathing, cyanosis,      MR, AR, DPC   AE, FS
       apnea, dyspnea, tachypnea, wheezing, stridor,
       inadequate respiratory effort, cough, hemoptysis, chest
       pain and respiratory failure

                                               154
GOAL: Diagnostic Testing

    Demonstrate knowledge and appropriately use common diagnostic tests in the inpatient
setting.

       Principal Educational Objectives – Diagnostic           Learning       Evaluation
       Testing                                                 Activities     Methods
 1.    Discuss indications for and limitations of standard     AR, DPC, MR,   AE, FS, MR
       laboratory tests and imaging studies including          CAT
       principles of sensitivity and specificity.
 2.    Demonstrate knowledge of the age-appropriate            AR, DPC, MR    AE, FS, MR
       normal readings of standard laboratory tests and
       imaging studies.
 3.    Interpret abnormalities in the context of specific      AR, DPC, MR    AE, FS, MR
       physiologic derangements.
 4.    Discuss therapeutic options for correction of           AR, DPC, MR,   AE, FS, MR
       abnormalities when appropriate.                         CAT
       Laboratory Tests

 a.    CBC - differential, platelet count, indices             AR, DPC, MR,   AE, FS, MR
                                                               CAT
 b.    Blood chemistries – electrolytes, glucose, calcium,     AR, DPC, MR,   AE, FS, MR
       and magnesium                                           CAT
 c.    Renal function tests                                    AR, DPC, MR,   AE, FS, MR
                                                               CAT
 d.    Tests of hepatic function and damage                    AR, DPC, MR,   AE, FS, MR
                                                               CAT
 e.    Serologic tests for infection (e.g., hepatitis, HIV)    AR, DPC, MR,   AE, FS, MR
                                                               CAT
 f.    ESR, CRP                                                AR, DPC, MR,   AE, FS, MR
                                                               CAT
 g.    Therapeutic drug concentrations                         AR, DPC, MR,   AE, FS, MR
                                                               CAT
 h.    Coagulation studies                                     AR, DPC, MR,   AE, FS, MR
                                                               CAT
 i.    Arterial, capillary and venous blood gases              AR, DPC, MR,   AE, FS, MR
                                                               CAT
 j.    Cultures for bacterial, viral and fungal pathogens      AR, DPC, MR,   AE, FS, MR
                                                               CAT
 k.    Urinalysis                                              AR, DPC, MR,   AE, FS, MR
                                                               CAT
 l.    CSF analysis                                            AR, DPC, MR,   AE, FS, MR
                                                               CAT
 m.    Gram stain                                              AR, DPC, MR,   AE, FS, MR
                                                               CAT
 n.    Stool studies                                           AR, DPC, MR,   AE, FS, MR
                                                               CAT
 o.    Other fluid studies (e.g. pleural fluid, joint fluid)   AR, DPC, MR,   AE, FS, MR
                                                               CAT


                                                  155
       Imaging Studies

 a.    Plain radiographs of the chest, extremities, abdomen,       AR, DPC, MR,    AE, FS, MR
       skull and sinuses                                           CAT
 b.    Other techniques such as CT, MRI, angiography,              AR, DPC, MR,    AE, FS, MR
       ultrasound, nuclear scans (interpretation not               CAT
       expected) and contrast studies
 c.    Lateral neck x-rays                                         AR, DPC, MR,    AE, FS, MR
                                                                   CAT
       Skin Testing

 a.    PPD/Controls placement and interpretation                   AR, DPC, MR,    AE, FS, MR
                                                                   CAT
       Other Testing

 a.    Appropriately order/use electrocardiogram and               AR, DPC, MR,    AE, FS, MR
       echocardiogram                                              CAT

GOAL: Monitoring and Therapeutic Modalities

      Demonstrate understanding of how to utilize physiologic monitoring and special
technology in the general inpatient pediatric setting.

      Principal Educational Objectives – Monitoring and             Learning       Evaluation
      Therapeutic Modalities                                        Activities     Methods
 1.   Discuss appropriate monitoring techniques for age and         DPC, MR, AR,   AE, FS,
      clinical setting, describe the indications and limitations    FS
      of and interpret the results and measurement of the
      following monitoring modalities: body temperature,
      cardiac, respiratory, pulse oximetry, blood pressure,
      peak flow rates, mental status and food monitoring
      (intake, output).
 2.   Participate in the daily care of technologically              DPC, MR, AR,   AE, FS,
      dependent children and children that require parenteral       FS
      nutrition, enteral tube feedings and/or respiratory
      support.
 3.   Discuss critical issues for the ongoing management of         DPC, MR, AR,   AE, FS,
      technologically dependent children in the hospital and at     FS
      home.
 4.   Demonstrate the skills for assessing and managing             DPC, MR, AR,   AE, FS, DSP
      pain.                                                         FS, PALS
 5.   Discuss the appropriate use of the following                  DPC, MR, AR,   AE, FS
      treatments/techniques: universal precautions,                 FS
      nasogastric tube placement, and administration of
      nebulized medication




                                              156
C. Practice-Based Learning and Improvement

GOAL: Management and Decision-Making

       Utilize a logical and appropriate clinical approach to the care of hospitalized children
applying decision-making and problem solving skills.

        Principal Educational Objectives – Management                    Learning            Evaluation
        and Decision-Making                                              Activities         Methods
  1.    Develop and apply decision-making and problem                    AR, MR, FS,        AE, FS, MR
        solving skills in the care of hospitalized children.             CAT, EBM
  2.    Actively seek relevant information for patient care              AR, MR, FS,        AE, FS
        decisions and apply this knowledge appropriately.                CAT, EBM
  3.    Assess quality control and quality improvement                   M&M                AE, FS
        processes and utilize results to improve patient care
        practices.
  4.    Participate in chart audits as part of the quality               M&M                AE, FS
        assurance process. Utilize this process to improve
        charting and patient care.
  5.    Prioritize needs of patients in a logical order.                 AR, MR, DPC, FS    AE, FS


D. Interpersonal Skills and Communication

GOAL: Teamwork and Consultation

      Function as part of an interdisciplinary team on a general pediatric ward, as a primary
provider (PGY-1).

       Principal Educational Objectives – Teamwork and                   Learning Activities Evaluation
       Consultation                                                                          Methods
  1.   Communicate well and work effectively with fellow                 AR, DPC, FS         AE, FS
       residents, attendings, consultants, nurses, ancillary staff and
       referring physicians.
  2.   Develop and demonstrate skills as a team participant (PGY-        AR, DPC, FS, MR    AE, FS
       1) in the care of pediatric patients.
  3.   Present information concisely and clearly both verbally and       AR, DPC, FS        AE, FS
       in writing on patients to other members of the health care
       team.
  4.   Communicate with the primary care giver in an effective           DPC, FS            AE, FS
       and timely manner. Assist the primary care giver in
       assuring continuity of care for the patient.
  5.   Know the role of hospital and managed care case managers          DPC, FS, MDR       AE, FS
       and work with them to optimize health care outcomes.
  6.   Communicate with families in a developmentally, culturally-       DPC, FS, E/C, LL   AE, FS, TYPD
       sensitive manner that provides families/patient with the
       information they need to understand the illness/injury,
       participate in the care, give informed consent, and prevent
       future injury or dysfunction.


                                                   157
  7.    Communicate with families in a developmentally, culturally- DPC, FS, E/C, LL AE, FS, TYPD
        sensitive manner that provides families/patient with the
        information they need regarding end of life issues.
  8.    Effectively listen to the concerns of patients and their    DPC, FS, E/C, LL AE, FS, TYPD
        families and respond with appropriate information and
        support.
  9.   Communicate to a given family and child the impact of DPC, FS, E/C, MDR AE, FS
       each phase of care on the final health care outcome,
       the psychosocial impact of illness on the child and
       family, and the financial burden to the family and the
       health care system.

GOAL: Medical Records

        Maintain accurate, timely and legally appropriate medical records in the hospital
inpatient setting.

       Principal Educational Objectives – Medical                   Learning               Evaluation
       Records                                                      Activities            Methods
 1.    Write daily notes that clearly document the patient’s        DPC, FS               AE, FS
       progress, relevant investigations and treatment plan.
 2.    Ascertain which patients require more frequent               DPC, FS               AE, FS
       documentation and ensure that this documentation
       takes place.
 3.    Prepare appropriate discharge summaries, transfer            DPC, FS               AE, FS
       notes and off-service notes, including written
       communication with the primary care provider.


E. Professionalism

GOAL: Patient Support and Advocacy

       Provide sensitive support to patients and families of children with acute and
chronic illnesses. Demonstrate accountability for patient care.

        Principal Educational Objectives – Patient Support                  Learning       Evaluation
                              and Advocacy                                  Activities      Methods
  1.   Interact professionally with patients, families, colleagues and AR, MR, DPC, FS    AE, FS, PDR
       all members of the health care team.
  2.   Accept professional responsibility as the primary care          AR, MR, DPC, FS    AE, FS
       physician for patients under his/her care.
  3.   Appreciate the social context of illness.                       AR, MR, DPC, FS,   AE, FS
                                                                       E/C, MDR
  4.   Know when and how to request a pediatric specialty              AR, MR, DPC, FS    AE, FS
       consult.
  5.   Know when and how to request ethics consultation and AR, MR, DPC, FS,              AE, FS
       how best to utilize the advice provided.                        E/C, MDR
  6.   Demonstrate sensitivity and awareness in dealing with AR, MR, DPC, FS,             AE, FS, TYPD


                                                 158
        end of life issues in the hospital setting.                       E/C, MDR, LL


GOAL: Professional Conduct

                 Demonstrate commitment to following ethical and professional principles and to on-going
professional development.

          Principal Educational Objectives – Professional                      Learning            Evaluation
                                  Conduct                                      Activities           Methods
  1.    Demonstrate knowledge of ethical concepts of                      AR, MR, DPC, FS,        AE, FS, TYPD
        confidentiality, consent, autonomy and justice.                   E/C, LL
  2.    Demonstrate knowledge of professionalism concepts                 AR, MR, FS, DPC,        AE, FS, TYPD
        such as integrity, altruism and conflict of interest.             E/C, LL
  3.    Increase self-awareness to identify methods to                    NC, GR, E/C             AE, FS, PDR
        manage personal and professional sources of stress
        and burnout.
  4.    Increase knowledge and awareness of personal risks                NC, GR, E/C             AE, FS, PDR
        concerning drug/alcohol abuse for self and colleagues,
        including referral, treatment and follow-up.


F. Systems-Based Practice

GOAL: Teamwork and Consultation

                 Function as part of an interdisciplinary team on a general pediatric ward, as a primary provider
and as a consulting pediatrician.

         Principal Educational Objectives – Teamwork and                   Learning                 Evaluation
         Consultation                                                      Activities              Methods
  1.     Discuss the role of the pediatric consultant in the               AR, MR, DPC, FS         AE, FS
         inpatient setting.
  2.     Describe the role of hospital and managed care case               AR, MR, DPC,            AE, FS
         managers. Work with these case managers to                        FS, MDR
         provide optimal health care.

GOAL: Patient Support and Advocacy

                Provide sensitive support to patients and families of children with acute illness and arrange for
on-going support and/or preventive services at discharge.

         Principal Educational Objectives – Patient                        Learning                 Evaluation
         Support and Advocacy                                              Activities              Methods
  1.     Discuss the unique problems in the care of children               AR, MR, DPC,            AE, FS
         with multiple problems or chronic illness and serve as            FS, MDR
         an advocate and case manager for these patients.
  2.     Discuss the community services available to patients              AR, MR, DPC,            AE, FS
         with multiple handicaps.                                          FS, MDR



                                                      159
GOAL: Financial Issues and Cost Control

                     Demonstrate knowledge of key aspects of cost control, billing and reimbursement in the hospital
inpatient setting.

          Principal Educational Objectives – Financial                        Learning                 Evaluation
          Issues and Cost Control                                             Activities              Methods
  1.      Discuss the common mechanisms of inpatient cost                     AR, MR, MDR             AE, FS
          control in managed care settings, including pre-
          authorization, concurrent review, discharge planning
          and guidelines.
  2.      Utilize consultants and other resources appropriately.              AR, MR, MDR             AE, FS, MR

  3.      Demonstrate sensitivity to the financial status of                  AR, MR, MDR             AE, FS
          patients; utilize resources appropriately for
          patients/families needing financial assistance.
  4.      Discuss the cost of hospitalization and commonly                    AR, MR, MDR             AE, FS
          utilized medications, procedures and tests.
  5.      Discuss common billing codes and documentation                      AR, MR, MDR, LL         AE, FS,
          procedures.                                                                                 TYPD




                                                         160
    PEDIATRIC EMERGENCY MEDICINE AND AMBULATORY ACUTE
                    ILLNESS ROTATIONS
Residents are assigned to Lyndon B. Johnson General Hospital (“LBJ”) for the emergency medicine
rotation. Residents are assigned a two week rotation at the LBJ emergency room during the
Transitional Year. Pediatric residents and PGY-1 Transitional year residents have a one-month
rotation at the Kid’s Place in the Hermann Professional Building (HPB), where they see ambulatory
patients scheduled for a sick visit. Faculty attendings from The University of Texas Medical School
at Houston Department of Emergency Medicine supervise the residents in the Emergency Rooms at
LBJ. Faculty from The University of Texas Medical School at Houston Department of Pediatrics
supervise residents at the Kid’s Place clinic. Adherence to an 80-hour work week is mandated for
the emergency medicine rotation and the ambulatory acute illness rotation.

Transitional Year Interns majoring in Pediatrics are required to take Pediatric Advanced Life Support
(“PALS”).

  Legend for Learning Activities
  AR – Attending Rounds        E/C – Ethics/Communication                     NC – Noon Conferences
                               Conferences                                    PALS – Pediatric Advanced
  DPC – Direct Patient Care    FS – Faculty Supervision                       Life Support
  CAT – Critically Appraised   GR – Grand Rounds                              RC – Research Conference
  Topics                       JC – Journal Club                              Rounds/Conference
  EBM – Evidence-Based         LL – Lunch & Learn Series                      SS – Senior Seminar
  Medicine Course              MR – Morning Report                            SL – Subspecialty Lectures
  DSP – Directly Supervised
  Procedures


  Legend for Evaluation Methods for Residents
  AE – Attending Evaluations                                   PDR – Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures                         FS – Faculty Supervision & Feedback
  MR – Morning Report                                          TYPD – Transitional Year Program Director
  PR – Peer Review


Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the
goal, the third column lists the most relevant learning activities for that goal, and the fourth column indicates
the correlating evaluation methods for that goal.




                                                      161
A. Patient Care
GOAL: Assess, resuscitate, and stabilize critically ill or injured children in the Emergency
Center in a timely manner.
                                                                     Learning         Evaluation
       Principal Educational Objectives
                                                                     Activities       Methods
 5.    Recognize and evaluate urgent patients by performing          DPC, SL, FS      AE, FS,
       the primary survey for all patients in an efficient manner,                    TYPD
       formulate a differential diagnosis, differentiate between
       cardiogenic, distributive and hypovolemic shock and
       assist in evaluating and stabilizing a child with multiple
       traumas.
 2.    Establish and manage the airways of infants, children         PALS, DPC, SL,   AE, FS,
       and adolescents recognizing the need for assistance           FS, LL           TYPD
       with ventilation and/or oxygenation.
 3.    Demonstrate proficiency in the following techniques:          PALS, DPC, SL,   AE, FS,
       proper airway positioning, administration of                  FS, LL           TYPD
       supplemental oxygen, bag-valve-mask ventilation, nasal
       and oral airways, endotracheal intubation, mechanical
       ventilation, and C-spine immobilization to protect the
       airway in a head trauma patient.
 4.    Discuss indications and describe technique for and            PALS, DPS, SL,   AE, FS,
       complications of nasotracheal intubation and                  FS, LL           TYPD
       emergency cricothyroidotomy.
 5.    Recognize the need for vascular access including              PALS, DPC, SL,   AE, FS, PDR
       diagnosing and managing early and late signs of shock.        FS
 6.    Establish vascular access in the critically ill child as      PALS, DPC, SL,   AE, FS,
       indicated.                                                    FS, LL           TYPD
 7.    Demonstrate proficiency in the following techniques:          PALS, DPC, SL,   AE, FS,
       cannulation of peripheral veins, intraosseous needle          FS, LL           TYPD
       insertion and umbilical vessel cannulation.
 8.    Explain indications and describe the technique for            PALS, DPC, SL,   AE, FS,
       central venous access and arterial access.                    FS, LL           TYPD
 9.    Manage fluid and pressor therapy in the initial               PALS, DPC, SL,   AE, FS
       resuscitation of patients in distributive, hypovolemic and    FS
       cardiogenic shock.
 10.   Demonstrate proficiency at cardiopulmonary                    PALS, DPC, SL,   AE, FS,
       resuscitation by obtaining and maintaining certification      FS, LL           TYPD
       as a provider of APLS (PGY-2s) and PALS (PGY-1s),
       directing resuscitation efforts in mock codes and in
       actual emergency situations, and using resuscitation
       drugs appropriately.

GOAL: Continuum of care

    Manage the continuum of care for children with acute illness/injury from initial
presentation (i.e. office, clinic emergency center) through acute hospital care(including
transfer in and out of PICU) discharge, home health services and office follow-up care.



                                               162
                Principal Educational Objectives- Continuum        Learning           Evaluation
                of Care                                            Activities         Methods
            1. Review past medical history, family history,        AR, DPC FS         AE, FS,
               immunizations and development                                          TYPD
6.              Provide acute patient care , diagnosis,            AR, DPC,           AE, FS, MR,
                stabilization and management of a variety of       CAT, FS, GR,       DSP
                acute illnesses                                    JC, MR, NC,SL
            3. Participate in (PGY-1) decision –making             AR, DPC, FS,       AE, FS, MR
               regarding transfer to PICU                          MR
            4. Communicate with a given family and child the       AR, DPC, E/C,      AE, FS
               impact of each phase of care on the final           FS
               healthcare outcome. Assess the psychosocial
               impact of illness on the child and family and the
               financial burden to the family and the healthcare
               system.


GOAL: Assess, diagnose and appropriately treat or refer infants, children and
adolescents that present with the following common signs and symptoms in the
Emergency Center or as a sick visit in the ambulatory clinic.

                                                                         Learning         Evaluation
          Principal Educational Objectives
                                                                         Activities       Methods
     1.   Gather essential and accurate information using                DPC, GR, JC,     AE, FS,
          problem-focused interview, exam and diagnostic studies. NC, SL, MR, FS          TYPD
     2.   Formulate a differential diagnosis with appropriate            DPC, GR, JC,     AE, FS,
          epidemiologic considerations.                                  NC, SL, MR, FS   TYPD
     3.   Make decisions using clinical problem-solving skills,          DPC, FS, JC,     AE, FS,
          consultants and referrals as appropriate.                      EBM, CAT, FS     TYPD
     4.   Carry out patient care management plans, with special          DPC, GR, JC,     AE, FS,
          attention to urgency, whether admission is indicated, and NC, SL, MR, FS        TYPD
          where to complete the evaluation and management.
     5.   Communicate with families in a developmentally,                DPC, E/C, FS     AE, FS,
          culturally-sensitive manner and provide families/patients                       TYPD
          with the information they need to understand the
          illness/injury, participate in the care, give informed
          consent and prevent further injury or dysfunction.
     6.   Arrange appropriate follow-up and patient education at         DPC, FS          AE, FS,
          the time of discharge.                                                          TYPD
     7.   Evaluate and manage the following signs and symptoms DPC, SL, NC,               AE, FS,
          that present in the Emergency Center or as a sick visit in GR, PALS, FS         TYPD
          the ambulatory setting:
          a.General: septic or ill-appearing infant/child,               DPC, FS, JL,     AE, FS
               unexplained crying, fever, hypothermia, acute life        NC
               threatening event (ALTE), sudden death, weight loss,
               failure to thrive, agitated/disturbed child, dehydration,
               alleged or suspected child abuse or neglect, fatigue,

                                                  163
          malaise, and exercise intolerance.

      b.Allergy/Immunology: acute allergic reactions               DPC, FS, JL    FS, AE

      c. Cardiorespiratory: apnea, respiratory distress,           DPC, FS, JL    FS, AE
         tachypnea or shortness of breath, respiratory failure,
         cyanosis, tachycardia, bradycardia, cough, wheezing,
         chest pain, palpitations, stridor, hypertension,
         hypotension (including orthostatic), syncope
      d.Dental: tooth injury or loss, pain or trauma of the     DPC, FS, JL       FS, AE
         mouth, jaw or tooth
      e.Dermatologic: skin rash, hair loss, itching             DPC, FS, SL       FS, AE

      f. EENT: dizziness, nosebleed, sore throat, painful          DPC, SL        FS, AE
          swallowing, earache, ear discharge, sudden hearing
          loss, red eye, abnormal pupils or eye movement,
          visual disturbances, eye pain
      g.Endocrine: heat/cold intolerance, polydipsia,              DPC, SL        FS, AE
          polyphagia
      h.GI: Abdominal pain, distension, diarrhea, vomiting         DPC, SL        FS, AE
          (bilious and non-bilious), constipation, GI bleeding,
          jaundice, difficulty swallowing
      i. GU/Renal: Edema, decreased or increased urination,        DPC, SL        FS, AE
          urinary frequency or urgency, bloody or discolored
          urine, dysuria, groin or scrotal mass or pain
      j. GYN: Menstrual problems, vaginal bleeding, vaginal        DPC, SL        FS, AE
          discharge
      k. Hematology/Oncology: Abnormal bleeding, bruising,         DPC, FS, SL    AE, FS
          petechiae, masses, hepatosplenomegaly,
          lymphadenopathy, pallor, acute illness or fever in a
          neutropenic child/cancer patient
      l. Musculoskeletal: limb pain, limp, arthralgia, joint       DPC, FS, SL,   AE, FS
          swelling, inability to move an extremity, trauma, back   NC
          pain
      m. Neurological: ataxia, spasticity, abnormal                NC, DPC, FS,   AE, FS
          movements, coma, lethargy, confusion, fainting           SL
          spells, seizures, headache, weakness or paralysis,
          bulging fontanel, stiff neck, head injury, dizziness
      n.Psychiatric: depression, suicidal ideation, hysteria,      DPC, FS, JL    AE, FS
          anxiety, hallucinations, violent behavior
      o.Surgery/trauma: trauma, lacerations, burns, acute          GR, DPC,       AE, FS
          abdomen                                                  EPLS, FS, SL

GOAL: Recognize and manage infants, children and adolescents that present with the
following common conditions.

                                                                   Learning       Evaluation
      Principal Educational Objectives
                                                                   Activities     Methods
 1.   Evaluate and manage the following common conditions:         DPC, SL, NC,   AE, FS, PDR
                                                                   GR, FS

                                               164
a.Allergy/Immunology: Asthma, anaphylaxis,                     DPC, SL, NC,   AE, FS
     angioedema, urticaria, serum sickness, HIV/AIDS,          GR, FS
     acute illness in an immunocompromised child
b.Cardiovascular: acute hypertension, congestive               DPC, SL, NC,   AE, FS
     heart failure, pericarditis, cardiomyopathy,              FS
     dysrythmias (asystole, bradycardia, SVT, ventricular
     fibrillation and tachycardia, atrial fibrillation and
     flutter, electromechanical dissociation), shock
     (hypovolemic, cardiogenic, distributive), Kawasaki’s
     disease, acute illness in a patient with congenital
     heart disease
c. Dermatology: acute drug reactions, contact                  DPC, SL, FS    AE, FS
     dermatitis, bacterial, viral and fungal infections of
     skin and hair, scabies, pediculosis, cutaneous
     manifestations of systemic and/or contagious
     diseases
d.Endocrine/Metabolic: diabetes and ketoacidosis,              DPC, SL, FS    AE, FS
     hypoglycemia, hypocalcemia, hypo- and
     hypernatremia, diabetes insipidus, SIADH, acute
     illness in a child with underlying endocrine/metabolic
     disease
e.GI/surgical: acute abdomen, peritonitis, bowel               DPC, SL, FS    AE, FS
     obstruction, ileus, appendicitis, malrotation, peptic
     ulcer disease, pyloric stenosis, intussusception,
     incarcerated hernia, gastroenteritis, hepatitis,
     hepatosplenomegaly, gastroesophageal reflux,
     dehydration, constipation, biliary tract disease,
     inflammatory bowel disease, upper and lower GI
     tract bleeding, pancreatitis, foreign body in GI tract,
     caustic ingestion
f. GU/renal: acute renal failure, hematuria, proteinuria,      FR, DPC, SL,   AE, FS
     urinary tract infection, phimosis, paraphimosis,          FS
     balanitis, labial adhesions, testicular torsion,
     epididymitis, STD, edema, renal lithiasis, acute
     illness in a child on chronic dialysis or with
     transplanted kidney
g.GYN: dysfunctional vaginal bleeding, PID, pregnancy          SL, DPC, FS    AE, FS
     (intrauterine, ectopic, abortion), cervicitis, ovarian
     torsion, ruptured ovarian cyst, sexually transmitted
     diseases
h.Hematology/Oncology: sickle cell pain crisis,                SL, DPC, FS    AE, FS
     sequestration and chest syndrome, fever in a child
     with sickle cell disease or leukemia, anemia,
     thrombocytopenia, coagulopathy, hemophilia with
     acute trauma, possible tumor (masses), Henoch
     Schönlein purpura
i. Infectious Disease: Otitis media/externa, pharyngitis,      SL, DPC, FS    AE, FS
     stomatitis, cervical adenitis, cellulitis, dental
     abscess, sinusitis, meningitis, encephalitis,
     sepsis/bacteremia, fever without source, infected

                                         165
    wounds and bites, pelvic inflammatory disease,
    warts, HIV
j. Neurological: Altered mental status, migraine,               NC, SL, DPC,   AE, FS
    muscle contraction headache, febrile seizures,              FS, GR
    afebrile seizures, status epilepticus,
    paresis/paralysis, ataxia, shunt
    malfunction/infection, increased intracranial
    pressure, brain tumor
k. Ophthalmologic: corneal abrasion, conjunctivitis,            SL, DPC, FS    DSP, AE, FS
    ocular foreign body, penetrating trauma to the globe,
    hyphema
l. Orthopedic: gait disturbance, sprains, strains,              NC, SL, DPC,   DSP, AE, FS
    fractures, arthritis, osteomyelitis, septic arthritis,      FS
    common dislocations, Osgood Slatter’s Disease
m. Otolaryngologic: epistaxis, foreign body aspiration,         SL, DPC, FS    AE, FS
    peritonsillar or retropharyngeal abscess
n.Pulmonary: respiratory failure, pneumonia,                    SL, DPC, FS    AE, FS
    epiglottitis, bacterial tracheitis, croup, asthma, status
    asthmaticus, foreign body aspiration, pneumothorax,
    bronchiolitis, pleural effusion, smoke inhalation,
    acute illness in a child with cystic fibrosis, BPD,
    SIDS
o.Trauma/surgical: Burns, closed head injury, skull             SL, DPC, FS    AE, FS
    fractures, intracranial hemorrhages (subdural,
    epidural, subarachnoid), soft tissue injury (including
    lacerations, abrasions, and contusions), common
    dental injuries
p.Toxins/environmental injuries: ingestion/poisoning            GR, DPC, FS,   AE, FS
    with an emphasis on common poisons                          SL
    (acetaminophen, iron, hydrocarbons, tricyclic
    antidepressants, cough and cold medicines, street
    drugs including cocaine. Toxins with antidotes,
    such as digoxin, benzodiazepines, and narcotics.
    Bite and sting injuries, submersion, electrical injury,
    heat and cold injury
q.Psychiatric: depression, suicide attempt/ideation,            DPC, FS, SL    AE, FS
    combative patient, conversion reaction, panic
    attacks
r. Rheumatologic: joint pain, soft tissue pain, arthritis,      DPC, FS, SL    AE, FS
    lupus, dermatomyositis
s. Social: child abuse or neglect, sexual abuse, rape,          DPC, FS, SL    AE, FS
    substance abuse, domestic violence




                                          166
GOAL: Management and Decision-Making

     Develop a logical and appropriate clinical approach to the care of hospitalized
children.

             Principal Educational Objectives-               Learning        Evaluation
             management of Decision making                   Activities      Methods
         1. Utilize principles of decision- making and         AR, DPC       AE, FS
            problem solving skills in the care of children as
            out-patients
         2. Identify and prioritize patients’ medical problems AR, DPC       AE, FS
            and generate appropriate differential diagnoses


Goal: Patient support and advocacy

     Provide sensitive support to patients and families of children with acute illness and
arrange for on-going support-and/or preventive services at discharge.


             Principle Educational Objectives-Patient        Learning        Evaluation
             Support and Advocacy                            Activities      Methods
         1. Demonstrate the skills necessary for assessing   AR, MR, DPC,    DSP, AE
            and managing pain.                               PALS, DSP
         2. Treat families in a non-judgmental, culturally   AR, MR, DPC,    AE, FS,
            sensitive manner                                 E/C, LL         TYPD


B. Medical Knowledge

GOAL: Establishing a Diagnosis

   Develop a differential diagnosis; formulate and appropriate work-up with diagnostic tests
to establish a diagnosis. Develop an appropriate treatment plan for diagnosis.


             Principal Educational Objectives                Learning         Evaluation
                                                             Activities       Methods
        1.   Create a differential diagnosis with age        MR, AR, DPC      AE,FS
             appropriate considerations.
         2. Discuss the pathophysiological basis for the     MR, AR, DPC      AE, FS
            disease or injury
          3 Discuss indications for hospitalization and      MR, AR, DPC      AE, FS
            formulate a plan for in-patient diagnosis and
            management

                                                167
GOAL: Discuss common diagnostic tests and imaging studies utilized in the emergency center and
ambulatory acute care setting. Appropriately utilize diagnostic tests and imaging studies as needed in the
care of infants, children and adolescents.

                                                                           Learning              Evaluation
        Principal Educational Objectives
                                                                           Activities            Methods
  1.    Select and interpret results of common diagnostic tests            DPC, NC, SL,          AE, FS,
        in the Emergency Center setting.                                   GR, FS                TYPD
  2.    Discuss age-appropriate normals for lab studies.                   DPC, NC, SL,          AE, FS,
                                                                           GR, FS                TYPD
  3.    Discuss diagnostic test properties including the use of            DPC, NC, SL,          AE, FS,
        sensitivity, specificity, positive predictive value, negative      GR, FS, EBM,          TYPD
        predictive value, likelihood ratios, and receiver                  CAT
        operating characteristic curves to assess test utility in
        clinical settings.
  4.    Interpret results in the context of the care of a specific         DPC, NC, SL,          AE, FS,
        patient.                                                           GR, FS                TYPD
  5.    Discuss therapeutic options for correction of                      DPC, NC, SL,          AE, FS,
        abnormalities.                                                     GR, FS                TYPD
  6.    Appropriately utilize the following laboratory studies:            DPC, NC, SL,          AE, FS,
                                                                           GR, FS                TYPD
        a.CBC with differential count, platelets, RBC indices              DPC, SL, FS           AE, FS
        b.Bacterial, viral and fungal cultures and rapid screens           DPC, SL, FS           AE, FS
        c. Serologic tests for infection                                   DPC, SL, FS           AE, FS
        d.Blood chemistries: electrolytes, calcium, magnesium,             DPC, SL, FS           AE, FS
            phosphate, and glucose
        e.Arterial, venous and capillary blood gases                       DPC, SL, FS           AE, FS
        f. Renal function tests                                            DPC, SL, FS           AE, FS
        g.Tests of hepatic function and damage                             DPC, SL, FS           AE, FS
        h.Drug levels and toxic screens                                    DPC, SL, FS           AE, FS
        i. Gram stain, wet mount                                           JL, FS                AE, FS
        j. Urinalysis                                                      DPC, SL, FS           AE, FS
        k. CSF studies                                                     DPC, SL, FS           AE, FS
        l. Stool studies                                                   DPC, SL, FS           AE, FS
        m. Coagulation studies                                             DPC, SL, FS           AE, FS

        n.Pregnancy test (urine, blood)                                    DPC, SL, FS           AE, FS
        o.Other fluid studies (e.g., pleural fluid, joint aspiration       DPC, SL, FS           AE, FS
            fluid)
  7.    Appropriately utilize the following imaging or radiologic          DPC, NC, SL,          AE, FS,
        studies:                                                           FS                    PDR
        a.Plain radiographs of chest, skull, extremity bones,              DPC, NC, SL,          AE, FS
                                                                           FS

                                                     168
            abdomen, cervical spine
        b.More sophisticated techniques such as CT, MRI,                DPC, NC, SL,        AE, FS
            ultrasound, and nuclear scans (interpretation not           FS
            required)
        c. Contrast enema for suspected intussusception or              DPC, NC, SL,        AE, FS
            upper GI series for suspected malrotation                   FS
  8.    Appropriately utilize the following screening and               DPC, NC, SL,        AE, FS,
        diagnostic studies:                                             FS                  PDR
        a.Electrocardiogram                                             DPC, NC, SL, FS     AE, FS
        b.Screening audiogram/tympanogram                               DPC, FS, SL         AE, FS

        c. Vision screening                                             DPC, FS, SL         AE, FS
        d.Appropriate urgent use of echocardiography                    DPC, FS, SL         AE, FS

GOAL: Discuss the use of physiologic monitoring and special technology and treatment in the Emergency
Center.

                                                                        Learning            Evaluation
        Principal Educational Objectives
                                                                        Activities          Methods
  1.    Discuss the indications, contraindications and                  DPC, NC, SL,        AE, FS, PDR
        complications of physiologic monitoring and special             FS
        technology.
  2.    Demonstrate appropriate use of technique for treatment          DPC, NC, SL, FS     AE, FS, PDR
        for children for varying ages.
  3.    Interpret results of monitoring based on method used,           DPC, NC, SL, FS     AE, FS, PDR
        age, and clinical situation.
  4.    Appropriately use the following monitoring techniques:          DPC, NC, SL, FS     AE, FS, PDR
        a.Physiologic monitoring of temperature, blood                  FS, PALS, DPC,      AE, FS
           pressure, heart rate, respirations                           SL
        b.Pulse oximetry                                                FS, PALS, DPC,      AE, FS
                                                                        SL
        c. Capnometry/end-tidal CO2                                     FS, PALS, DPC,      AE, FS
                                                                        SL
  5.    Appropriately use the following treatments and                  DPC, NC, SL,        AE, FS, PDR
        techniques:                                                     FS
        a.Universal precautions                                         DPC, PALS, FS,      AE, FS, DSP
                                                                        SL
        b.Gastrointestinal decontamination for poisoning                DPC, SL, FS         AE, FS, DSP
        c. Administration of nebulized medication                       DPC, FS, SL         AE, FS, DSP
        d.Injury, wound and burn care                                   DPC, FS, SL         AE, FS, DSP
        e.Suturing and dermabond                                        DPC, FS, SL,        AE, FS,
                                                                        LL                  DSP, TYPD
        f. Splinting and casting                                        DPC, FS, SL, LL     AE, FS,
                                                                                            DSP, TYPD
        g.Oxygen delivering system                                      FS, PALS, SL,       AE, FS,
                                                                        DPC, LL             TYPD

                                                  169
 6.    Appropriately use the following methods of anesthesia               DPC, NC, SL,      AE, FS, PDR
       or pain management:                                                 FS
       a.Methods for recognizing and evaluating pain                       PALS              AE DSP, FS
       b.Topical/local/regional anesthesia                                 FS, DPC, SL,      AE, DSP, FS
                                                                           PALS
       c. Sedatives, non-narcotic and narcotic analgesics                  FS, DPC, SL       AE, FS
       d.Behavioral techniques and supportive care                         FS, DPC, SL       AE, FS
       e.Other non-pharmacologic methods of pain control                   FS, D PC, SL      AE, FS




C. Practice-Based Learning and Improvement

       Principal Educational Objectives – Management                     Learning            Evaluation
       and Decision-Making                                               Activities         Methods
 1.    Develop and apply decision-making and problem                     AR, MR, FS,        AE, FS, MR
       solving skills in the care of children as out-patients.           CAT, EBM
 2.    Actively seek relevant information for patient care               AR, MR, FS,        AE, FS
       decisions and apply this knowledge appropriately.                 CAT, EBM
 3.    Assess quality control and quality improvement                    M&M                AE, FS
       processes and utilize results to improve patient care
       practices.
 5.    Prioritize needs of patients in a logical order.                  AR, MR, DPC, FS    AE, FS

D. Interpersonal Skills and Communication

GOAL: Teamwork and Consultation

Function as part of an interdisciplinary team on a general pediatric ward, as a primary
provider (PGY-1).

       Principal Educational Objectives – Teamwork and                   Learning Activities Evaluation
       Consultation                                                                          Methods
  1.   Communicate well and work effectively with fellow                 AR, DPC, FS         AE, FS
       residents, attendings, consultants, nurses, ancillary staff and
       referring physicians.
  2.   Develop and demonstrate skills as a team participant (PGY-        AR, DPC, FS, MR    AE, FS
       1) in the care of pediatric patients.
  3.   Present information concisely and clearly both verbally and       AR, DPC, FS        AE, FS
       in writing on patients to other members of the health care
       team.
  4.   Communicate with the primary care giver in an effective           DPC, FS            AE, FS
       and timely manner. Assist the primary care giver in
       assuring continuity of care for the patient.
  5.   Know the role of hospital and managed care case managers          DPC, FS, MDR       AE, FS
       and work with them to optimize health care outcomes.
  6.   Communicate with families in a developmentally, culturally-       DPC, FS, E/C, LL   AE, FS, TYPD

                                                   170
         sensitive manner that provides families/patient with the
         information they need to understand the illness/injury,
         participate in the care, give informed consent, and prevent
         future injury or dysfunction.
  7.     Communicate with families in a developmentally, culturally- DPC, FS, E/C, LL AE, FS, TYPD
         sensitive manner that provides families/patient with the
         information they need regarding end of life issues.
  8.     Effectively listen to the concerns of patients and their    DPC, FS, E/C, LL AE, FS, TYPD
         families and respond with appropriate information and
         support.
  9.    Communicate to a given family and child the impact of DPC, FS, E/C, MDR AE, FS
        each phase of care on the final health care outcome,
        the psychosocial impact of illness on the child and
        family, and the financial burden to the family and the
        health care system.




E. Professionalism

GOAL: Patient Support and Advocacy

Provide sensitive support to patients and families of children with acute and chronic
illnesses. Demonstrate accountability for patient care.

         Principal Educational Objectives – Patient Support                  Learning         Evaluation
                               and Advocacy                                  Activities        Methods
  1.    Interact professionally with patients, families, colleagues and AR, MR, DPC, FS      AE, FS, PDR
        all members of the health care team.
  2.    Accept professional responsibility as the primary care          AR, MR, DPC, FS      AE, FS
        physician for patients under his/her care.
  3.    Appreciate the social context of illness.                       AR, MR, DPC, FS,     AE, FS
                                                                        E/C, MDR
  4.    Know when and how to request a pediatric specialty              AR, MR, DPC, FS      AE, FS
        consult.
  5.    Know when and how to request ethics consultation and AR, MR, DPC, FS,                AE, FS
        how best to utilize the advice provided.                        E/C, MDR
  6.    Demonstrate sensitivity and awareness in dealing with AR, MR, DPC, FS,               AE, FS, TYPD
        end of life issues in the hospital setting.                     E/C, MDR, LL

GOAL: Professional Conduct

Demonstrate commitment to following ethical and professional principles and to on-going professional
development.

          Principal Educational Objectives – Professional                  Learning           Evaluation
                                Conduct                                    Activities          Methods
  1.    Demonstrate knowledge of ethical concepts of                  AR, MR, DPC, FS,       AE, FS, TYPD
        confidentiality, consent, autonomy and justice.               E/C, LL


                                                   171
  2.    Demonstrate knowledge of professionalism concepts                  AR, MR, FS, DPC,        AE, FS, TYPD
        such as integrity, altruism and conflict of interest.              E/C, LL
  3.    Increase self-awareness to identify methods to                     NC, GR, E/C             AE, FS, PDR
        manage personal and professional sources of stress
        and burnout.
  4.    Increase knowledge and awareness of personal risks                 NC, GR, E/C             AE, FS, PDR
        concerning drug/alcohol abuse for self and colleagues,
        including referral, treatment and follow-up.


F. Systems-Based Practice

GOAL: Patient Support and Advocacy

Provide sensitive support to patients and families of children with acute illness and arrange for on-going support
and/or preventive services at discharge.

         Principal Educational Objectives – Patient                        Learning                 Evaluation
         Support and Advocacy                                              Activities              Methods
  1.     Discuss the unique problems in the care of children               AR, MR, DPC,            AE, FS
         with multiple problems or chronic illness and serve as            FS, MDR
         an advocate and case manager for these patients.
  2.     Discuss the community services available to patients              AR, MR, DPC,            AE, FS
         with multiple handicaps.                                          FS, MDR




                                                      172
                           PEDIATRIC NEONATAL ICU ROTATION
Transitional Year residents may rotate in the Neonatal Intensive Care Unit (“NICU”) at Lyndon B. Johnson
General Hospital (“LBJ”). The NICU experience is comprised of a one-month block rotation. The team is
composed of a neonatology attending, a neonatology fellow, one PGY3, at times a PGY2 pediatric resident
(resident supervisor) and three to four interns.

The University of Texas Medical School at Houston full-time Pediatric faculty supervise residents during the NICU
Rotation. A neonatal faculty member is assigned to each of the NICU teams and rounds are conducted on all
patients with the residents seven days a week. Residents assigned to the NICU take call every fourth night.

PGY-1s are required to take the Neonatal Resuscitation Program prior to beginning clinical duties. Didactic
instruction in physiology and pathophysiology are provided during attending rounds and as a set of lectures in the
Newborn Medicine Sessions of the Resident Education Series. Residents are exposed to all forms of invasive and
non-invasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral and metabolic function.
A full-time neonatal nutritionist and clinical pharmacist round with the NICU team(s) and provide input/instruction
in the appropriate selection of nutrition, use of total parenteral nutrition, and use of various medications. Residents
work with a multidisciplinary team of case managers, social workers, home health care providers and high-risk
follow-up clinic physicians and nurses.

  Legend for Learning Activities
  AR – Attending Rounds                           GR – Grand Rounds                      OC – Outpatient clinics
  DPC – Direct Patient Care                       JC – Journal Club                      RC – Research Conference
  CAT – Critically Appraised Topics               MDR – Multidisciplinary Rounds         SC – Specialty
  E/C – Ethics/Communication                      MR – Morning Report                    Conferences
  Conferences                                     NC – Noon Conferences                  RS – Resident Seminar
  FS – Faculty Supervision                        NM – Neonatal ICU Manual and           SL – Subspecialty
                                                  Text                                   Lectures


  Legend for Evaluation Methods for Residents
  AE – Attending Evaluation                                    PDR – Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures                         FS – Faculty Supervision & Feedback
  MR – Morning Report

Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the goal,
the third column lists the most relevant learning activities for that goal, and the fourth column indicates the
correlating evaluation methods for that goal.




                                                        173
A. Patient Care

GOAL: Interpret the pediatrician’s role in and become an active advocate for programs to reduce
morbidity and mortality from high risk pregnancies.

       Principal Educational Objectives                          Learning         Evaluation
                                                                 Activities       Methods
 1.    Identify and describe strategies to reduce fetal and      AR, FS, GR, NC   AE, FS
       neonatal mortality.
 2.    Describe how to access the following:                     AR, FS, GR, SC   AE, FS
           a. Basic vital statistics that apply to newborns.
           b. Prenatal services available in this region.
           c. Neonatal transport systems.
 3.    Recognize potential adverse outcomes for the fetus and    AR, FS, SL       AEFS
       neonate of common prenatal and perinatal conditions,
       and demonstrate the pediatrician’s role in assessment
       and management strategies to minimize the risk to the
       fetus and/or newborn.


GOAL: Assess, resuscitate and stabilize critically ill neonates.

       Principal Educational Objectives                          Learning         Evaluation
                                                                 Activities       Methods
 1.    Explain and perform steps in resuscitation and            AR, DPC, SL,     AE, FS
       stabilization, particularly airway management, vascular   FS
       access, volume resuscitation, indications for and
       techniques of chest compressions, resuscitative
       pharmacology, and management of meconium
       deliveries.
 2.    Describe the common causes of acute deterioration in      AR, DPC, NM,     AE, FS
       previously stable NICU patients.                          MR, NC, SL, FS
 3.    Function appropriately in codes and neonatal              DPC, FS          AE, FS
       resuscitations as part of the NICU team.




                                                174
B. Medical Knowledge
GOAL: Evaluate and manage, under the supervision of a neonatologist, common signs and
symptoms of disease in premature newborns.

       Principal Educational Objectives                                     Learning          Evaluation
                                                                            Activities        Methods
 1.    Evaluate and manage patients with the signs and                      AR, DPC, SC,      AE, FS
       symptoms that present commonly in the NICU.                          SL, NM, FS,
       Examples are:                                                        GR, NC
         a. General: feeding problems, history of maternal
            infection or exposure, hyperthermia, hypothermia,
            intrauterine growth failure, irritability, jitteriness, large
            for gestational age, lethargy, poor post-natal weight
            gain, prematurity (various gestational ages)
         b. Cardiorespiratory
         c. Dermatologic
         d. GI/surgical
         e. Genetic/metabolic
         f. Hematologic
         g. Musculoskeletal
         h. Neurologic
         i. Parental stress
         j. Renal/urologic
 2.    Recognize and manage common conditions in patients                   AR, DPC, SC,      AE, FS
       encountered in the NICU. Examples are:                               SL, NM
         a. General: congenital malformations
         b. Cardiovascular
         c. Genetic, endocrine disorders
         d. GI/nutrition
         e. Hematologic conditions
         f. Infectious disease
         g. Neurologic disorders
         h. Pulmonary disorders
         i. Renal
         j. Surgery (assess and participate in management
            under supervision of a pediatric surgeon or cardiac
            surgeon)


GOAL: Order and discuss the indications for, limitations of, and interpretation of laboratory and
imaging studies unique to the NICU setting.

       Principal Educational Objectives                                     Learning          Evaluation
                                                                            Activities        Methods
 1.    Demonstrate understanding of common diagnostic tests                 AR, NC, SL, SC,   AE, FS
       and imaging studies used in the NICU.                                NM
 2.    Know or be able to locate readily gestational age-                   AR, NM            AE, FS
       appropriate ranges.
                                                       175
 3.    Interpret laboratory results in the context of the specific    AR, NC, SL, SC,   AE, FS
       patient.                                                       NM
 4.    Discuss therapeutic options for correction of                  AR, NC, SL, SC,   AE, FS
       abnormalities.                                                 NM


GOAL: Apply physiologic monitoring, special technology and therapeutic modalities used
commonly in the care of the fetus and the newborn.

       Principal Educational Objectives                               Learning          Evaluation
                                                                      Activities        Methods
 1.    Use appropriately the following monitoring and                 AR, SL, NM, FS,   AE, FS
       therapeutic techniques in NICU:                                DPC
            a. Physiologic monitoring of temperature, pulse,
                respiration, blood pressure.
            b. Pulse oximetry.
            c. Neonatal pain and drug withdrawal scales.
 2.    Discuss the following techniques and procedures used           AR, SL, NC, FS    AE, FS
       by obstetricians and perinatal specialists:
            a. Fetal ultrasound for size and anatomy.
            b. Fetal heart rate monitors.
            c. Scalp and cord blood sampling.
            d. Amniocentesis.
 3.    Utilize appropriately treatments and techniques in the         AR, SL, SC,       AE, FS
       NICU. Monitor effects and anticipate potential                 NM, FS, DPC
       complications specific to each procedure.
 4.    Describe home medical equipment and services                   AR, SL, SC,       AE, FS
       needed for oxygen-dependent and technology-                    NM, FS
       dependent graduates of the NICU (oxygen, apnea
       monitor, ventilator, home hyperalimentation, etc.)



C. Practice-Based Learning and Improvement.

GOAL: Utilize a logical and appropriate approach to the care of newborns applying principles of
evidence-based decision-making and problem solving skills.

       Principal Educational Objectives                              Learning           Evaluation
                                                                     Activities         Methods
 1.    Develop and apply decision-making and problem                 FS, CAT, DPC,      AE, FS
       solving skills in the care of newborns and infants.           AR
 2.    Demonstrate ability to prioritize care needs: identify        FS, DPC, AR        AE, FS
       urgent issues that require immediate attention, use
       appropriate timing for diagnostic and therapeutic
       interventions and adjust pace to acuity and volume.
                                                  176
 3.     Integrate professional scholarship including electronic FS, DPC, CAT,            AE, FS
        and print literature with emphasis on the integration of AR
        basic science with clinical medicine into decision-
        making regarding patient care.


D. Interpersonal & Communication Skills

GOAL: Participate effectively with specialists and other health professionals in the care of the
fetus and the newborn.

       Principal Educational Objectives                              Learning             Evaluation
                                                                     Activities           Methods
 1.    Present information concisely and clearly, both verbally      FS, DPC, AR          AE, FS
       and in writing, on patients to other members of the
       health care team.
 2.    Utilize consultants appropriately and communicate in          AR, SL, SC,          AE, FS
       an effective manner.                                          DPC


GOAL: Develop effective communication relationships with patients and their families.

       Principal Educational Objectives                                Learning Activities Evaluation
                                                                                           Methods
  1.    Communicate with families in a developmentally, culturally- FS, DPC, E/C, AR       AE, FS
        sensitive manner that provides families with the information
        they need to understand the illness/injury, participate in the
        care, give informed consent, and prevent future injury or
        dysfunction.
  2.    Effectively listen to the concerns of families and respond     FS, DPC, E/C        AE, FS
        with appropriate information and support.
  3.   Communicate to families the impact of the illness               FS, DPC, E/C, AR    AE, FS
       and/or complications on the final health care outcome.
       Understand the psychosocial impact of illness on the
       family, and the financial burden to the family and the
       health care system.




                                                  177
E. Professionalism

GOAL: Maintain standards of professional performance in the NICU.

         Principal Educational Objectives                                Learning                Evaluation
                                                                         Activities             Methods
  1.     Use a logical and effective approach to the                     AR, DPC, SL, SC, AE, FS
         assessment and daily management of ill neonates                 FS
         and their families, under the guidance of a
         neonatologist, using evidence-based decision-
         making and problem solving skills.
  2.     Demonstrate a commitment to acquiring the                       AR, DPC, FS            AE, FS
         knowledge base expected of general pediatricians
         caring for neonates.
  3.     Maintain accurate, timely, and legally appropriate              DPC                    AE, FS
         medical records in the critical care setting of the NICU.


F. Systems-Based Practice

GOAL: Interact with other health professionals, specialists and other providers who refer patients to the Neonatal
Intensive Care Unit (NICU).

         Principal Educational Objectives                                Learning                Evaluation
                                                                         Activities             Methods
  1.     Discuss the role of the neonatologist and provide               FS, DPC, AR            AE, FS
         appropriate consultation in the NICU setting.
  2.     Share information with the Primary Care Provider                AR, DPC                AE, FS
         who will care for the patient after the illness.


GOAL: Demonstrate knowledge of key aspects of health care systems including cost control, billing and
reimbursement in the NICU.

         Principal Educational Objectives                                Learning                Evaluation
                                                                         Activities             Methods
  1.     Utilize consultants and other resources appropriately.          FS, DPC, AR            AE, FS

  2.     Demonstrate sensitivity to the financial status of              FS, DPC, AR            AE, FS
         patients; utilize resources appropriately for
         patients/families needing financial assistance.
  4.     Discuss common billing codes and documentation                  FS, AR, DPC            AE, FS
         procedures for the NICU.




                                                      178
                          PEDIATRIC PULMONOLOGY ROTATION
Residents assigned to the pediatric pulmonology rotation work in a team of one senior Pediatric or
Medicine-Pediatric resident (PGY-2 or 3/4) and one Transitional or Anesthesia PGY-1 resident.
Residents will experience treating outpatient and hospitalized pediatric pulmonary patients.

The rotation occurs at Memorial Hermann Children’s Hospital (MHCH), The University of Texas Outpatient
Clinics, and at The Lyndon B. Johnson General Hospital (LBJ) and clinics. Residents see Pulmonary inpatient and
outpatient consults and participate in the management of outpatients followed by the Pulmonary service. In
addition, they provide care of continuity for patients on the pediatric pulmonary inpatient service. Transitional year
residents are supervised by faculty in the Department of Pediatrics Division of Pulmonology.

The Pediatric Pulmonology team consults on patients in General Pediatrics, PSCU, PICU, NICU and NBSCU at
Memorial Hermann Children’s Hospital. The team or attending will occasionally provide consultation to patients
at LBJ Hospital, MD Anderson Cancer Center, and St. Joseph’s Hospital.

Care for asthmatic patients at MHCH should be individualized to the child’s needs; however, the NEAPP
Guidelines for the Diagnosis and Management of Asthma has been translated into a clinical pathway with orders
and educational guidelines. Residents are encouraged to use these materials and individualize them to their
asthmatic patients. The pathway and orders are part of the reading packet. It is very important that patients get the
necessary education about disease process, medications, environmental control, emergency management and
follow-up care. Residents are a valuable part of the Pediatric Pulmonary Medicine Team and they will participate
in educating patients. As part of pulmonary training, residents will need to demonstrate proficiency in the following
areas of patient asthma education:

                          Peak flow meter use and interpretation
                          MDI (inhaler) and spacer use
                          Nebulizer use
                          Environmental control measures
                          Asthma disease process
                          Emergency management
                          Asthma medications

Residents should keep in mind the discharge needs of their inpatients and plan for needed equipment (e.g.
Nebulizers) in advance to facilitate discharge.


  Legend for Learning Activities
  AR – Attending Rounds                        GR – Grand Rounds                  NC – Noon Conferences
  DPC – Direct Patient Care                                                       PALS – Pediatric Advanced Life
  CAT – Critically Appraised Topics            JC – Journal Club                  Support
  E/C – Ethics/Communication                   LL – Lunch & Learn Series          RC – Research Conference
  Conferences                                  MR – Morning Report                SS – Senior Seminar
  FS – Faculty Supervision                     MDR – Multidisciplinary            SL – Subspecialty Lectures
                                               Rounds

                                                        179
  Legend for Evaluation Methods for Residents
  AE – Attending Evaluation                                 PDR – Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures                      TYPD - Transitional Year Program Director
  MR – Morning Report                                       FS – Faculty Supervision & Feedback

Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the goal,
the third column lists the most relevant learning activities for that goal, and the fourth column indicates the
correlating evaluation methods for that goal.

A. Patient Care

GOAL: Diagnose and manage pulmonary problems in children under the guidance of a Pediatric
Pulmonologist.

        Principal Educational Objectives                                  Learning             Evaluation
                                                                          Activities           Methods
  1.    Diagnose and manage asthma. Discuss goals of                      AR, DPC, FS,         AE, FS, MR
        therapy, NAEPP guidelines, pharmacotherapy,                       NC, SL, MR
        environmental control, and guidelines for referral to a
        specialist.
  2.    Diagnose and manage infectious pulmonary disorders                AR, DPC, FS,         AE, FS, MR
        in children. Discuss the pathophysiology and                      NC, SL, MR
        management of RSV bronchiolitis, pneumonia, TB,
        Pertusis, and Aspergillosis.
  3.    Diagnose and manage premature infants with                        AR, DPC, FS,         AE, FS, MR
        bronchopulmonary dysplasia (BPD) and infants with                 NC, SL, MR
        chronic disorders.
  4.    Diagnose and manage patients with chronic restrictive             AR, DPC, FS,         AE, FS, MR
        and obstructive lung disorders, recurrent infections and          NC, SL, MR
        hemoptysis.

GOAL: Diagnose and manage, under the supervision of a Pediatric Pulmonologist or Intensivist,
patients with acute respiratory failure.

        Principal Educational Objectives                                  Learning             Evaluation
                                                                          Activities           Methods
  1.    Discuss the recognition of patients with impending                AR, DPC, FS,         AE, FS
        respiratory failure.                                              SL
  2.    Discuss/demonstrate airway management in patients in              AR, DPC, FS,         AE, FS,
        respiratory failure.                                              PALS, LL             PDR, TYPD
  3.    Discuss ventilation management of children with                   AR, DPC, FS,         AE, FS,
        respiratory failure.                                              SL, LL               PDR, TYPD



                                                      180
B. Medical Knowledge

GOAL: Recognize and discuss the management of noninfectious pulmonary disorders in
children and neonates.

      Principal Educational Objectives                             Learning     Evaluation
                                                                   Activities   Methods
 1.   Discuss the differential diagnosis for the wheezing child.   AR, NC, SL   AE

 2.   Discuss the pathophysiology and management of the            AR, NC, SL   AE
      following noninfectious pulmonary disorders in children:
 a.   Chest wall deformities                                       AR, NC, SL   AE

 b.   Compression syndromes                                        AR, NC, SL   AE

 c.   Obstructive sleep apnea                                      AR, NC, SL   AE

 d.   Aspiration                                                   AR, NC, SL   AE

 e.   Foreign body aspiration                                      AR, NC, SL   AE

 f.   Bronchiectatsis                                              AR, NC, SL   AE

 g.   ILD                                                          AR, NC, SL   AE

 h.   Pulmonary hemorrhage                                         AR, NC, SL   AE

 i.   Emphysema                                                    AR, NC, SL   AE

 j.   Alpha-1-Antitrypsin deficiency                               AR, NC, SL   AE

 k.   Hypersensitivity pneumonitis                                 AR, NC, SL   AE

 l.   Eosinophilic diseases                                        AR, NC, SL   AE

 m.   Cystic Fibrosis                                              AR, NC, SL   AE

 n.   ARDS                                                         AR, NC, SL   AE

 o.   Ciliary Dyskinesia                                           AR, NC, SL   AE

 p.   Sarciodosis                                                  AR, NC, SL   AE

 q.   Cor pulmonale                                                AR, NC, SL   AE

 r.   Childhood cancer and GVH disease                             AR, NC, SL   AE

 s.   Acute Chest/Sickle Cell                                      AR, NC, SL   AE

 t.   SIDS, ALTE                                                   AR, NC, SL   AE


                                                181
 3.   Discuss the pathophysiology and management of            AR, NC, SL       AE
      neonates with the following pulmonary disorders:
 a.   Apnea                                                    AR, NC, SL       AE

 b.   Transient Tachypnea of Newborn                           AR, NC, SL       AE

 c.   Pneumonia                                                AR, NC, SL       AE

 d.   Meconium Aspiration                                      AR, NC, SL       AE

 e.   Persistent Pulmonary Hypertension                        AR, NC, SL       AE

 f.   Pulmonary hypoplasia                                     AR, NC, SL       AE

 g.   PIE-airblock syndromes                                   AR, NC, SL       AE

 h.   Pulmonary edema                                          AR, NC, SL       AE

 i.   Pulmonary hemorrhage                                     AR, NC, SL       AE

 j.   Surfactant protein B deficiency                          AR, NC, SL       AE

 k.   Airwall disorders                                        AR, NC, SL       AE

 l.   Vocal cord paralysis                                     AR, NC, SL       AE

 m.   Subglottic stenosis                                      AR, NC, SL       AE


GOAL: Demonstrate skill in performing basic pulmonary diagnostic procedures.

      Principal Educational Objectives                         Learning         Evaluation
                                                               Activities       Methods
 1.   Demonstrate basic interpretation of spirometry.          AR, FS, DPC      AE, FS

 2.   Discuss the use of bronchoscopy as a diagnostic tool.    AR, FS, DPC,     AE, FS
                                                               SL

C. Practice-Based Learning and Improvement

GOAL: Develop a logical, evidence-based approach to the management of chronic obstructive
  lung disorders in children.

       Principal Educational Objectives                       Learning           Evaluation
                                                              Activities        Methods
 1.    Evaluate the evidence for various treatment            AR, FS, CAT, SL   AE, FS
       modalities for asthma and discuss management
       based on that evidence.



                                              182
 2.    Evaluate the evidence for various therapeutic              AR, FS, CAT, SL       AE, FS
       regimes in Cystic Fibrosis and discuss a
       management plan based on that evidence.


D. Interpersonal Skills and Communication

GOAL: Learn the role of a Pediatric consultant.

       Principal Educational Objectives                                                 Evaluation
                                                                  Learning Activities
                                                                                        Methods
  1.   Discuss the role of primary care physicians in the        AR, FS, E/C, SL        AE, FS
       management of children with chronic pulmonary conditions.
  2.   Demonstrate effective communication with primary care     AR, FS, E/C, SL        AE, FS
       physicians requesting consultation from the Pediatric
       Pulmonary Service.

GOAL: Communicate effectively with patients and families of children with chronic respiratory
conditions.

       Principal Educational Objectives                                                 Evaluation
                                                                  Learning Activities
                                                                                        Methods
  1.   Educate patients with asthma and their families about      AR, FS, E/C           AE, FS
       environmental factors relating to asthma.
  2.   Demonstrate sensitivity and skill in dealing with          AR, FS, E/C           AE, FS
       patients/families with newly diagnosed chronic pulmonary
       diseases such as Cystic Fibrosis.

E. Professionalism

GOAL: Learn the role of a Pediatric consultant.

       Principal Educational Objectives                                                 Evaluation
                                                                  Learning Activities
                                                                                        Methods
  1.   Discuss the role of primary care physicians in the        AR, FS, E/C, SL        AE, FS
       management of children with chronic pulmonary conditions.
  2.   Demonstrate effective communication with primary care     AR, FS, E/C, SL        AE, FS
       physicians requesting consultation from the Pediatric
       Pulmonary Service.




                                                 183
GOAL: Communicate effectively with patients and families of children with chronic respiratory
conditions.

         Principal Educational Objectives                                                        Evaluation
                                                                         Learning Activities
                                                                                                 Methods
   1.    Educate patients with asthma and their families about           AR, FS, E/C             AE, FS
         environmental factors relating to asthma.
   2.    Demonstrate sensitivity and skill in dealing with               AR, FS, E/C             AE, FS
         patients/families with newly diagnosed chronic pulmonary
         diseases such as Cystic Fibrosis.


F. Systems-Based Practice

GOAL: Function as part of an interdisciplinary team to provide care for patients with chronic respiratory diseases.

         Principal Educational Objectives                                Learning                 Evaluation
                                                                         Activities              Methods
  1.     Work with respiratory therapists, case managers, and            AR, FS, MDR             AE, FS
         nutritionists to develop a plan for outpatient
         management of patients with chronic pulmonary
         disorders such as cystic fibrosis and asthma.
  2.     Discuss local and state resources available to assist           AR, MDR, SL             AE, FS
         families in the care of a child with a chronic
         respiratory condition such as cystic fibrosis.




                                                       184
                           PEDIATRIC NEPHROLOGY ROTATION
Transitional Year residents assigned to the pediatric nephrology rotation work in a team of one senior
Pediatric or Medicine-Pediatric resident (PGY-3 or 4) and one or more PGY-1s. The rotation is a one
month block rotation. Residents are exposed to both outpatient and hospitalized pediatric nephrology
patients. The rotation occurs at Memorial Hermann Children’s Hospital (MHCH), The University of
Texas Outpatient Clinics, UT MD Anderson Cancer Center and LBJ Hospital.

Residents provide primary care for inpatients admitted to the Nephrology service at MHCH, see
Nephrology consults on other services, and see patients in the Nephrology/Hypertension outpatient
clinics. Residents are supervised by faculty in the Department of Pediatrics Division of Nephrology and
Hypertension. Transitional year residents may choose Nephrology as one of their Pediatric rotations.

Residents are expected to attend all appropriate Department of Pediatric conferences. In addition, residents will
attend the Division of Pediatric Nephrology/Adult Nephrology teaching conferences. Adherence to the 80-hour
work week is mandated.

        Pediatric Nephrology:

        Daily Teaching Rounds
        Multidisciplinary Rounds
        Pediatric Renal Grand Rounds
        Patient Care Conference
        Monthly Pediatric Uroradiology Conference
        Pediatric Renal Transplant Conference
        Pediatric Resident Seminar

        Pediatric Nephrology/Adult Nephrology:

        Renal Biopsy Conference
        Clinical Case Conference
        Renal Grand Rounds
        Visiting Professor Program

        Mandatory Clinics:

       Monday afternoon - General Nephrology Clinic
       Tuesday afternoon - General Nephrology Clinic
       Wednesday afternoon - General Nephrology Clinic alternating weekly with Pediatric
                             Renal Transplant Clinic
       Thursday afternoon - Hypertension Clinic or LBJ Pediatric Nephrology Clinic

        Clinics to attend if time allows:

        Thursday- Peritoneal dialysis clinic
        Daily hemodialysis rounds
        Wednesday afternoon- UTMDACC Pediatric Nephrology Clinic
                                                      185
The goals and objectives listed below are covered through rounding on the inpatient service, discussions about
patients seen on an outpatient basis, various conferences, pediatric nephrology/hypertension syllabus updated
yearly to contain the best review articles on general topics in pediatric nephrology and hypertension that would be
important for general pediatricians to know, review articles and other handouts. Residents will have access to
computer-based literature searches as well. Each resident is required to give a talk on a nephrologic subject of
his/her choice during the rotation. The resident is also responsible for preparing a patient care conference at
morning report with attending supervision and attendance. Residents will also be evaluated on their effectiveness
and willingness to teach medical students. Residents will also learn nephrology related skills such as the urinalysis,
techniques for accurate 24 hour urine collection and interpretation, how to take an accurate BP, ambulatory blood
pressure monitoring, the use of random urine studies and interpretation of radiographic tests related to nephrology.
Residents will have a check-list of nephrologic conditions that must be covered during the month through patient
care, lecture, rounds or reading. Residents receive a pre-test to evaluate their level of knowledge at the start of the
rotation and a final written examination containing many questions from PREP and the Pediatric Nephrology
Boards as well as those developed by the faculty. This examination must be passed in order for the resident to
receive credit for the rotation.



  Legend for Learning Activities
  AR – Attending Rounds                            GR – Grand Rounds                     OC Outpatient clinics
  DPC – Direct Patient Care                        JC – Journal Club                     RC – Research Conference
  CAT – Critically Appraised Topics                MDR – Multidisciplinary               SC – Specialty
  E/C – Ethics/Communication                       Rounds                                Conferences1
  Conferences                                      MR – Morning Report                   RS – Resident Seminar
  FS – Faculty Supervision                         NC – Noon Conferences                 SL – Subspecialty
  LL-Lunch and Learn Series                        NM – Nephrology Manual and            Lectures
                                                   Text


  Legend for Evaluation Methods for Residents
  AE – Attending Evaluation                                     PDR – Program Director’s Review (quarterly)
  DSP – Directly Supervised Procedures                          FS – Faculty Supervision & Feedback
  MR – Morning Report                                           TYPD-Transitional Year Program Director


Specialty Conferences include Renal Biopsy Conference, Clinical Case Conference, Renal Grand Rounds, and Pediatric
Uroradiology Conference, Journal Club, Renal Transplant Conference, Pediatric Renal Grand Rounds




                                                         186
Principal Educational Goals and Objectives by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table lists the goal,
the third column lists the most relevant learning activities for that goal, and the fourth column indicates the
correlating evaluation methods for that goal.

A. Patient Care

GOAL: Differentiate between normal and pathological states related to the renal system.

        Principal Educational Objectives                                  Learning             Evaluation
                                                                          Activities           Methods
  1.    Describe the age related changes in blood pressure                AR, SL, NM,          AE, FS
        including normal ranges from birth through adolescence            SC, FS
        and learn to personally measure BP accurately.
  2.    Differentiate transient hematuria from clinically                 AR, SL, NM,          AE, FS
        significant gross or microscopic hematuria.                       SC, DPC, FS
  3.    Differentiate transient proteinuria from clinically               AR, SL, NM,          AE, FS
        significant persistent or intermittent proteinuria.               SC, DPC, FS
  4.    Describe the findings on clinical history and examination         AR, SL, NM,          AE, FS
        that would suggest renal disease and require further              SC, FS
        evaluation and treatment.
  5.    Apply measures of glomerular and tubular function to              AR, SL, NM,          AE, FS
        determine normal versus abnormal kidney function.                 SC, FS
        Learn to perform urinalysis

GOAL: Evaluate and treat common renal diseases presenting in the outpatient setting.

        Principal Educational Objectives                                  Learning             Evaluation
                                                                          Activities           Methods
  1.    Evaluate and manage the child with a urinary tract                AR, DPC, NM,         AE, FS
        infection.                                                        MR, NC, SL, FS
  2.    Determine the need for and the extent of the                      AR, DPC, NM,         AE, FS
        radiographic evaluation required for the patient with a           MR, NC, SL, FS
        UTI.
  3.    Evaluate the patient who presents with hematuria                  AR, DPC, NM,         AE, FS
        and/or proteinuria.                                               MR, NC, SL, FS
  4.    Diagnose and manage the patient with hypertension.                AR, DPC, NM,         AE, FS
                                                                          MR, NC, SL, FS
  5.    Learn to diagnose and manage common fluid and                     AR, DPC, NM,         AE, FS
        electrolyte disturbances with intravenous and oral                MR, NC, SL, FS
        rehydration.



                                                      187
GOAL: Evaluate and manage complicated diseases of the renal system in consultation with a
Pediatric Nephrologist.

       Principal Educational Objectives                            Learning          Evaluation
                                                                   Activities        Methods
 1.    Diagnose and manage patients with acute and chronic         AR, DPC, SC,      AE, FS
       glomerulonephritis including nephrotic syndrome.            SL, NM, FS
 2.    Diagnose and manage renal diseases associated with          AR, DPC, SC,      AE, FS
       systemic diseases, e.g., systemic lupus, hemolytic-         SL, NM
       uremic syndrome, ANCA positive diseases, and
       Henoch-Schoenlein Purpura.
 3.    Diagnose and manage issues related to bone disease          AR, DPC, SC,      AE, FS
       commonly seen in children with renal disease including      SL, NM
       growth retardation, renal tubular acidosis, and rickets

B. Medical Knowledge

GOAL: Describe kidney development and measures of renal function.

       Principal Educational Objectives                            Learning          Evaluation
                                                                   Activities        Methods
 1.    Discuss the normal neonatal development of the kidney       AR, NC, SL, SC,   AE
       both anatomy and function.                                  NM
 2.    Discuss measures of renal function including GFR,           AR, NC, SL, SC,   AE
       urinary concentration, proximal tubular function, and       NM
       acid-base handling.

GOAL: Discuss the physiology of issues related to renal function.

       Principal Educational Objectives                            Learning          Evaluation
                                                                   Activities        Methods
 1.    Discuss handling of drugs by the kidney and dosing of       AR, NC, SL, SC,   AE
       medication for chronic kidney disease                       NM
 2.    Discuss fluid and electrolyte problems in childhood.        AR, MR, NC,       AE
                                                                   SL, NM
 3.    Discuss structural problems of the kidney including         AR, MR, NC,       AE
       vesicoureteral reflux, obstructions of the urinary tract,   SL, NM
       urolithiasis and bladder dysfunction.
 4.    Discuss abnormal kidney development such as cystic          AR, MR, NC,       AE
       diseases of the kidney, hypoplasia, dysplasia,              SL, NM
       abnormalities of renal position, and prune belly
       syndrome




                                                  188
GOAL: Discuss issues involved with complicated renal disease generally managed by a
Pediatric Nephrologist.

        Principal Educational Objectives                                 Learning             Evaluation
                                                                         Activities           Methods
  1.    Discuss the etiologies, complications and diagnosis and          AR, SL, SC, NM       AE
        management of chronic kidney disease including
        osteodystrophy, anemia, growth failure, developmental
        delay, hyperlipidemia and progression to ESRD.
  2.    Discuss the principles of renal replacement therapy              AR, SL, SC, NM       AE
        including hemdialysis, peritoneal dialysis, CVVHD and
        SLED.
  3.    Discuss the principles and management of the child               AR, SL, SC, NM       AE
        with a renal transplant.


C. Professionalism and Interpersonal Skills and Communication

GOAL: Develop skills to effectively teach others.

         Principal Educational Objectives                              Learning                Evaluation
                                                                       Activities             Methods
  1.     Present a lecture on the nephrologic subject of               AR, DPC, SL, SC        AE, FS
         his/her choice and present a case conference at
         morning report and biopsy conference
  2.     Demonstrate instruction of medical students in an             AR, DPC, SL, SC        AE, FS
         effective, enthusiastic manner.


D. Systems-Based Practice

GOAL: Function as part of an interdisciplinary team in the management of children with renal diseases.

         Principal Educational Objectives                              Learning                Evaluation
                                                                       Activities             Methods
  1.     Discuss the psychosocial and financial aspects of the         AR, MDR, E/C           AE, FS
         child with renal disease.
  2.     Communicate and work effectively with                         AR, MDR, E/C           AE, FS
         psychiatrists/psychologists, Child Life, nutritionists,
         and case managers to provide financial and
         psychosocial support for children with end stage
         renal disease and renal transplant.



                                                     189
  3.     Discuss use of home and school monitoring of                    AR, MR, NC, SL,        AE
         disease including urinary dipsticks, and BP                     NM
         monitoring



    E. Practice Based Learning

GOAL: Learn to utilize and integrate technological advances in the care of children with renal disease

         Principal Educational Objectives                                Learning                Evaluation
                                                                         Activities             Methods
  1.     Learn to utilize electronic medical record to provide           AR, MDR, E/C,          AE, FS,
         documentation of patient’s medical care, provide                LL                     TYPD
         better communication among medical staff and the
         multiple patient care sites and communicate with
         referring physicians. Learn to utilize hand held
         technology to facilitate patient care. Learn HIPPA
         regulations governing privacy.
  2.     Residents are encouraged to be creative in trying to            AR, MDR, E/C           AE, FS
         improve technological or other area of medical
         practice that can improve medical care and
         communication




                                                      190
The University of Texas-Houston Health Science Center
Transitional Year Residency Program Curriculum
April, 2009

                                        Ophthalmology Elective

Transitional residents will work closely with the department faculty and residents during
their elective rotation. Their goals and objectives are as follows:

                  To gain understanding of the procedures involved in performing an ophthalmic
                   examination.
                  To be able to work with the basic equipment used in ophthalmology including the
                   slit lamp and ophthalmoscope.
                  To gain understanding of the identification and treatment of common ophthalmic
                   disorders including glaucoma, cataracts, and diabetic retinopathy.
                  To observe ophthalmic surgical procedures, and understand the general
                   indications and complications.

CONFERENCES

Attendance at all conferences is mandatory. Residents stationed at LBJ are also required to be present.
 Most conferences are held in the Raye and Ed White Conference Center in the Cizik Eye Clinic.
Attendance at each conference is recorded on the Conference Attendance Sheet present at each
conference. These are collected by the Chief Resident and turned in to the Department office. All
conference activities are recorded, including those off campus, special topics, practice management,
and review conferences.

The following conferences provide the core group of conferences, and additional topics are often
presented throughout the year.

Resident Curriculum/Basic and Clinical Science Curriculum (BCSC)
The curriculum is a series of lectures based on the American Academy of Ophthalmology’s The Basic
and Clinical Science Course in Ophthalmology (BCSC). These volumes provide the basis, but not the
sole source, for the major portion of the curriculum. These conferences are regularly scheduled,
according to topic, throughout the year. The entire course is repeated each year. The purpose of this
curriculum is to prepare the resident for an effective practice in ophthalmology, and to prepare the
resident for the Qualifying Board Examination in Ophthalmology at the end of the training period.
(Faculty Director: Judianne Kellaway, M.D.)

Case Conferences
Case Conferences are held several times a month. The purpose of these conferences is to present
interesting cases for discussion by the residents and faculty. This provides a very good experience for
careful observation, an essential skill in ophthalmology, as well as developing a fund of knowledge
through discussion of the case and its management, as well as very good practice for oral examinations.
 Residents will present cases on a rotating basis, and topics are assigned to provide comprehensive
coverage. Topics include a wide variety of subjects and are monitored by the Chief Resident and
Program Director. (Director: Chief Resident)

                                                 191
Grand Rounds
Grand Rounds are held on the second Thursday of each month. The format of Grand Rounds is the
presentation of cases by the residents and discussions with the faculty and guests. Grand Rounds are
attended by the visiting lecturer for the Houston Ophthalmological Society from September through
April.

Guest Lecturer
The guest speaker for Houston Ophthalmological Society presents a didactic lecture prior to Grand
Rounds every month. This occurs September through April on the second Thursday of the month.
(Faculty Directors: Robert M. Feldman, M.D.)

Journal Club
Journal Club is conducted once every month. The purpose of Journal Club is to develop good reading
habits which will keep the practicing ophthalmologist up to date in the years to come, to learn to critically
evaluate journal articles, to learn the various types of studies presented in the literature, and to develop
a broad base of fundamental knowledge from original journal articles. It is the responsibility of the
resident to read the three major ophthalmology journals in their entirety, (AJO, Ophthalmology, and
Archives of Ophthalmology) and be prepared to discuss any of the articles for that month. Other
assignments for Journal Club may include a review and discussion of the classic articles in various
specialties in ophthalmology. (Faculty Director: Nan Wang, M.D.)

Ethics Rounds
Ethic Rounds are held monthly. The purpose of Ethics Rounds is to provide the resident with thought-
provoking ethical, medicolegal, and socioeconomic issues in order to build a foundation for their future
practice. Residents will present cases on a rotating basis. (Faculty Director: Judianne Kellaway, M.D.)

Photo Conference
Photo Conference is held monthly. The format is presentation of a photograph of an ocular disease with
a discussion among faculty and residents. The residents are guided in discussion by questions from the
faculty until a differential diagnosis is developed. The format is very similar to the oral board
examination of the American Board of Ophthalmology. (Faculty Director: Richard S. Ruiz, M.D.)


Quality Assurance and M&M Conference
The topics of quality assurance and improving patient care are presented at several meetings
throughout the year. In addition, several resident meetings each year also address these issues.
(Faculty Director: Judianne Kellaway, M.D.)

  Legend for Learning Activities
  DSP – Directly Supervised    NC – Noon Conferences                  DPC – Direct Patient Care
  Procedures                   BCSC – Basic and Clinical
  JC – Journal Club            Science Curriculum
  M&M-Morbidity & Mortality    CC – Case Conferences
  GR – Grand Rounds            ER – Ethics Rounds

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                              PR – Peer Review
  PDR–Program Director’s Review (quarterly)               DSP – Directly Supervised Procedures
                                                    192
Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.

A. Patient Care

         Principal Educational Goals                                Learning             Evaluation
                                                                    Activities           Methods
 1.      Communicate effectively and demonstrate caring and                              AE
         respectful behavior when interacting with patients         DPC
         and their families
 2.      Gather essential and accurate information about their                           AE
                                                                    DPC
         patients.

B. Medical Knowledge

                                                                    Learning             Evaluation
        Principal Educational Goals
                                                                    Activities           Methods
 1.     Demonstrate evidence of having read about disease                                AE
                                                                    DPC
        processes seen in the clinic.
 2.     Show progress in being able to use data obtained                                 AE
        from the history and examination to formulate an            DPC, DSP
        appropriate diagnosis and plan.
 3.     List major differential diagnoses, especially sight                              AE
                                                                    DPC, GR
        threatening or life threatening entities
 4.     Perform an accurate and complete eye exam on                                     AE
                                                                    DPC
        patients


C. Interpersonal Skills and Communication

                                                                    Learning             Evaluation
        Principal Educational Goals
                                                                    Activities           Methods
 1.     Use effective listening skills.                             DPC                  AE

 2.     Work as a team member.                                      DPC                  AE

 3.     Ask for help when needed.                                   DPC                  AE

 4.     Demonstrate the ability to actively listen to the patient                        AE
                                                                  DPC
        and answer their questions appropriately.


                                                   193
5.    Demonstrate ability to effectively communicate with the               AE
      patient and family the nature of the disorder, the
      recommended treatment, and alternative treatment DPC
      options, and if the procedures is elective, the elective
      nature of the procedure.
6.    Communicate with the patient in a confidential manner. DPC            AE

7.    Observe and practice effective information exchange                   AE
                                                          DPC
      with patients and their families.
8.    Perform patient counseling in the presence of faculty.   DPC          AE


D.    Professionalism

      Principal Educational Goals                              Learning     Evaluation
                                                               Activities   Methods
1.    Demonstrate respect, compassion, and integrity.                       AE
                                                               DPC
2.    Be responsive to the needs of patients and society that               AE
                                                               DPC
      supersedes self-interest.
3.    Be professional and respectful in terms of                            AE
      responsibilities, appearance, communication, interaction DPC
      with patients, staff and ancillary office personnel.
4.    Adhere to high ethics and principles.                    DPC          AE

5.    Demonstrate compassion, kindness, patience and caring                 AE
                                                            DPC
      at all times to patients, family, and staff.

E. Practice-Based Learning and Improvement

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Study and evaluate own patient care with faculty input
      and discussion.
2.    Utilize evidence-based medicine to better assess and                  AE
                                                             DPC
      adjust patient care.
3.    Participate in discussions in clinic, grand rounds.      GR           AE

4.    Present at Journal Club.                                 JC           AE




                                                194
     F. Systems-Based Practice

                                                                 Learning     Evaluation
        Principal Educational Goals
                                                                 Activities   Methods
1.      Demonstrate the ability to effectively call on system                 AE
                                                                   DPC
        resources to provide care that is of optimal value.
2.      Practice cost effective health care and resource                      AE
                                                                   DPC
        allocation that does not compromise quality of care.
3.      Demonstrate an understanding of the role of different                 AE
        specialists and other health care professionals in overall DPC
        patient management.




                                                 195
The University of Texas-Houston Health Science Center
Orthopaedic Surgery Residency Program Curriculum


                        ORTHOPAEDIC INTERNSHIP ROTATION
Orthopaedic Internship rotations are based at Memorial Hermann Hospital and Lyndon B Johnson
Hospital. The goal of the orthopaedic rotation is to obtain broad based educational experience to create
a solid foundation of common orthopedic problems. Curriculum is designed based on the guidelines
provided by ACGME and follows the requirements of the American Board of Orthopaedic Surgery
(ABOS) for board certification.

From Orthopaedic Internship Rotation, it is expected that you as a resident will develop competencies in
the six broad categorical areas. These competencies are required of all residents for success as an
orthopaedic surgeon. The orthopaedic faculty will define and assist you in attaining the specific
knowledge, skills, and attitudes to meet these competencies.



  Legend for Learning Activities
  CC-Core Curriculum           JC – Journal Club                      SL – Subspecialty Lectures
  DPC – Direct Patient Care    IC - Indication Conference
  FS – Faculty Supervision     WC – Weekly Conference
  GR – Grand Rounds
  M&M-Morbidity & Mortality
  MR – Morning Report


  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                             PR – Peer Review
  PDR–Program Director’s Review (quarterly)              TS – Technical Skill Evaluation

Principal Educational Goals by Relevant Competency

The principal educational goals for residents on this rotation are indicated for each of the six ACGME
competencies in the tables below and numbered in the first column. The second column of the table
lists the goal, the third column lists the most relevant learning activities for that goal, and the fourth
column indicates the correlating evaluation methods for that goal.


A. Patient Care

Resident will be able to:

                                                                    Learning               Evaluation
        Principal Educational Goals
                                                                    Activities             Methods
                                                   196
  7.    Take a complete medical history and perform a                                AE
                                                                   DPC, CC, FS,
        careful and accurate physical examination. This
                                                                   MR, SL, IC
        includes evaluation of patient with acute trauma
  2.    Write concise, accurate and informative histories,         DPC, CC, FS,      AE
        physical examinations and progress notes.                  MR, SL, IC
  3.     Define and prioritize patients’ medical problems and      DPC, CC, FS,      AE
        generate appropriate differential diagnoses.               MR, SL, IC
  4.                                                               DPC, CC, FS,      AE
         Develop rational, evidence-based management
                                                                   MR, SL, IC, JC,
        strategies.
                                                                   WC
  5.    Make informed recommendations about preventive,                              AE
        diagnostic and therapeutic options and interventions       DPC, CC, FS,
        that are based on clinical judgment, scientific            MR, SL, IC, JC,
        evidence, and patient and family preferences               WC

  6.    Perform competently basic non-surgical and surgical        DPC, CC, FS,      AE, TS
        procedures to establish basis for further training.        MR, SL, IC, JC,
        These include close reduction of various extremity         WC
        fractures and dislocations, incision and drainage of
        abscesses, closure of simple wound, debridement of
        open fractures, care of patient in surgical intensive
        care unit, joint aspiration, placement of splints and
        casts, and application of skeletal traction pin.


B. Medical Knowledge

Resident will be able to:

                                                                   Learning          Evaluation
        Principal Educational Goals
                                                                   Activities        Methods
  1.    Expand clinically applicable knowledge base of the                           AE
                                                                   CC, GR, JC, IC,
        basic and clinical sciences underlying the care of
                                                                   SL
        patients.
  2.    Access and critically evaluate current medical                               AE
                                                                   CC, GR, JC, IC,
        information and scientific evidence relevant to patient
                                                                   SL
        care.
  3.    Understand basic pathophysiology, clinical                                   AE
                                                                   CC, GR, JC, IC,
        manifestations, diagnosis and management of
                                                                   SL
        surgical patients.
  4.    Recognize the indications for and basic interpretation     CC, GR, JC, IC,   AE
        of physical examination findings, plain radiographs,       SL
        CT scan and MRI
  5.    Learn indications for and basic interpretation of          CC, GR, JC, IC,   AE
        standard laboratory tests, including blood counts,         SL
        coagulation students, blood chemistry tests, joint fluid
        analyses, and microbiologic tests.
                                                 197
  6.                                                                                AE
        Interpretation of diagnostic tests, sensitivity,          CC, GR, JC, IC,
        specificity and predictive values.                        SL



C. Interpersonal Skills and Communication

Resident will be able to:

                                                                  Learning          Evaluation
        Principal Educational Goals
                                                                  Activities        Methods
  1.    Communicate effectively with patients and families.       DPC, FS           AE

  2.    Communicate effectively with physician colleagues at                        AE, PR
                                                                  DPC, FS, MR, WC
        all levels.
  3.    Communicate effectively with all non-physician
        members of the health care team to assure                 DPC, FS, MR       AE, PR
        comprehensive and timely care of hospitalized
        patients.
  4.    Present information concisely and clearly both verbal     DPC, FS, MR,      AE, PR, PDR
        and written form.                                         WC, M&M

D. Professionalism

Resident will be able to:

                                                                     Learning        Evaluation
                     Principal Educational Goals
                                                                     Activities       Methods
  1.   Interact professionally towards patients, families,        DPC, FS, MR,      AE
       colleagues, and all members of the health care team.       WC, M&M
  2.   Acceptance of professional responsibility as either the                      AE , PR
       admitting physician or consulting physician for patients DPC
       under his/her care
  3.   Appreciation of the social context of illness.             DPC, MR, WC       AE

  4.   Knowing when and how to request ethics consultation,                         AE
                                                                  DPC, MR
       and how best to utilize the advice provided.
  5.   Discuss the ethical concepts related to confidentiality,   CC, DPC, MR,      AE
       consent, autonomy and justice.                             WC, M&M
  6.   Discuss the professionalism concepts of integrity,                           AE, PR, PDR
       altruism and conflict of interest and how these            CC, DPC
       concepts impact patient care.
  7.   Increase self-awareness to identify methods to                               PDR
       manage personal and professional sources of stress         FS
       and burnout.



                                                   198
  8.   Demonstrate sensitivity and responsiveness to the                              AE
       gender, age, culture, religion, sexual preference,
                                                                    DPC, FS, MR
       socioeconomic status, beliefs, behaviors and
       disabilities of patients and professional colleagues

E. Practice-Based Learning and Improvement

Resident will be able to:

                                                                    Learning           Evaluation
        Principal Educational Goals
                                                                    Activities        Methods
  1.    Identify and acknowledge gaps in personal                   DPC, CC, GR,      AE
        knowledge/skills                                            JC, IC, WC, SL
  2.    Develop and implement strategies for filling gaps in        DPC, CC, GR,      AE
        knowledge and skills.                                       JC, IC, WC, SL
  3.    Demonstrate a commitment to professional                                      AE
        scholarship through the systematic and critical
                                                                    DPC, CC, GR,
        perusal of relevant print and electronic literature, with
                                                                    JC, IC, WC, SL
        emphases on integration of basic science with clinical
        medicine, and evaluation of information in light of the
        principles of evidence-based medicine

F. Systems-Based Practice

Resident will be able to:

                                                                    Learning           Evaluation
        Principal Educational Goals
                                                                    Activities        Methods
  1.    Discuss the resources necessary to care optimally for                         AE
                                                                    DPC
        patients
  2.    Use evidence-based, cost-conscious strategies in the                          AE
                                                                    DPC, CC, JC, GR
        care of patients.
  3.    Understanding when to ask for help and advice from                            AE
                                                                    DPC, MR, WC
        senior residents and attending physicians.
  5.    Collaborate with other members of the health care                             AE
                                                                    DPC
        team, including residents at all levels, medical
        students, nurses, clinical pharmacists, occupational
        therapists, physical therapists, social workers, case
        managers, discharge planners, clinical pharmacists
        and providers of home health services.
  6.    Appropriately request consultations with other
        medical subspecialists (internal medicine,                                    AE
                                                                    DPC
        rheumatology, infectious disease specialists), and
        effectively utilize the advice provided.



                                                  199
7.
     Appropriately request ethics consultations, and
                                                       DPC           AE
     effectively utilize the advice provided
8.   Compare and contrast the cost-effectiveness of                  AE
                                                       DPC, JC, GR
     diagnostic and treatment strategies.
9.   Demonstrate a willingness to learn from senior                  AE, PR
                                                       DPC, MR, WC
     residents.




                                             200
                  Duke Trauma Service – Memorial Hermann Hospital

The Memorial Hermann Hospital Duke Trauma Service rotation is a one month rotation to
which Transitional Year Residents are assigned. This service is the busiest level one
trauma center in the country. On this service the residents see a variety of blunt and
penetrating injuries. The Transitional Year residents work on a team consisting of a Chief
Resident (PGY 4 or 5), two or three PGY 3 Residents, two or three PGY 2 Residents and
from three to six interns. The team is lead by Trauma faculty and the Chief Resident.
During this rotation the Transitional Year resident will be able to demonstrate an
understanding of the pathophysiologic effect of blunt and penetrating trauma; demonstrate
the ability to effectively manage the surgical care of a patient with complex multisystem
injuries; and demonstrate knowledge of, and the ability to manage a variety of healthcare
services for trauma patients such as pre-hospital transportation, emergency department
care, in-hospital care, and rehabilitation.
Call is every third night (depending on the number of interns on the rotation) with
supervision from the Chief Resident and faculty. While on call the Transitional Year
Resident will attend to inpatients and respond to codes with supervision from the Chief
Resident. Adherence to the 80 hour work week is mandated.

       Legend for Learning Activities
       AR-Attending Rounds                         CC – Core Curriculum
       DPC – Direct Patient Care           DSP – Directly Supervised Procedures
       EBM – Evidence Based Medicine      FS – Faculty Supervision
       GR – Grand Rounds                  IL – Introductory Lecture Series
       LL – Lunch & Learn




       Legend for Evaluation of Methods for Residents
       AE – Attending Evaluations       DSP – Directly Supervised Procedures
       MR – Morning Report                      PDR – Program Director’s Review
       (quarterly)
       PR – Peer Review                 TYPD – Transitional Year Program Director



Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the
six ACGME competencies in the tables below and numbered in the first column. The
second column of the table lists the goal, the third column lists the most relevant learning
                                             201
activities for that goal, and the fourth column indicates the correlating evaluation methods
for that goal.
     A. Patient Care
       Principal Education Goals                              Learning       Evaluation
                                                              Activities     Methods
1.     Actively participate (with supervision) in the
       care of a trauma patient, including
           a.   Evaluation                                    AR, DPC, MR    AE
           b.   Resuscitation                                 AR, DPC, DSP   AE, DSP
           c. Operative Management                            DPC, DSP       DSP, AE
           d.   Intensive Care Unit (ICU) Management          AR, DPC, GR,   AE
                                                              MM
           e.   Management on the hospital wards              AR, DPC, MR    AE
           f.   Discharge Planning                            AR, DPC        AE
2.     Be able to safely and expeditiously perform:
           a.   Endotracheal intubation
                1. Oral                                       DSP            DSP, AE
                2. Nasal                                      DSP            DSP, AE
           b.   Diagnostic peritoneal lavage (DPL)            DSP            DSP, AE
           c. Tube thoracostomy                               DSP            DSP, AE
           d. Urinary bladder catheter insertion              DSP            DSP, AE
           e. Intravenous catheter insertion                  DSP            DSP, AE
           f.   Nasogastric tube insertion                    DSP            DSP, AE
3.     Be able to correctly apply and remove all types        DSP            DSP, AE
       of dressings and splints, including the vacuum
       pack dressing
4.     Be able to make and close, under supervision,          DSP            DSP, AE
       a variety of incisions and tie knots using sterile l
       technique.
5.     Be able to correctly assess nutritional needs          AR, MR, DPC    AE
       and institute necessary nutritional support.



                                                   202
6.    Correctly manage, with supervision, volume            DSP          DSP, AE, FS
      and pharmacologic treatment plans for patients
      during resuscitation and in the critical care unit.
7.    Correctly perform basic surgical procedures
      such as:
         a.   Laparotomy                                    DSP          DSP, AE
         b. Wound debridement                               DSP          DSP, AE
         c. Application of traction devices for both head   DSP          DSP, AE
            and extremities


     B. Medical Knowledge
      Principal Education Goals                             Learning     Evaluation
                                                            Activities   Methods
1.    Be able to correctly describe the anatomy, and
      physiology of all body systems affected by
      trauma and should be able to accurately
      describe the initial functional evaluation of the:
         a.   Central nervous system                        AR, DPC      AE
         b. Cardiovascular system                           AR, DPC      AE
         c. Extremity function                              AR, DPC      AE
         d. Pulmonary system                                AR, DPC      AE
         e. Nutritional status                              AR, DPC      AE
         f.   Gastrointestinal system                       AR, DPC      AE
2.    Be able to accurately relate the anatomy,
      physiology, and pathology of the following that
      are applicable to the general management of
      trauma patients:
         a.   Central nervous system                        AR, DPC      AE
         b. Musculoskeletal system                          AR, DPC      AE
         c. Hand/forearm                                    AR, DPC      AE
         d. Ear, nose and throat                            AR, DPC      AE
         e. Ophthalmology                                   AR, DPC      AE



                                               203
3.   Be able to correctly outline the basis             AR, MR, GR,    AE
     techniques of evaluation and resuscitation of      DPC
     trauma patients using the American College of
     Surgeons (ACS) Advanced Trauma Life
     Support (ATLS) Protocol.
4.   Be able to correctly describe proper wound         AR, MR, GR,    AE
     care management in the emergency                   DPC
     department and other settings.
5.   Be able to correctly describe the management
     of the following drains and tubes:
        a.   Nasogastric tube (NGT)                     DSP, DPC       AE, DSP
        b. Urinary bladder catheter                     DSP, DPC       AE, DSP
        c. Chest tube                                   DSP, DPC       AE, DSP
        d. Central venous line                          DSP, DPC       AE, DSP
6.   Be able to correctly explain the basic surgical
     skills, including:
        a.   Sterile technique                          DSP, DPC       AE, DSP
        b. Incisions                                    DSP, DPC, LL   AE, DSP,
                                                                       TYPD
        c. Wound closures                               DSP, DPC, LL   AE, DSP,
                                                                       TYPD
        d. Knot tying                                   DSP, DPC       AE, DSP
        e. Handling of tissues                          DSP, DPC       AE, DSP
        f.   Selection/use of operating instruments     DSP, DPC       AE, DSP
        g. Universal precautions                        DSP, DPC       AE, DSP
7.   Be able to correctly outline the management of     DSP, DPC,      AE, DSP
     trauma involving the musculoskeletal system,       AR, MR
     including the need for and application of casts,
     splints, and traction.
8.   Be able to correctly describe the basic            AR, MR         AE
     principles of pharmacological support for
     trauma, resuscitation, and intensive care unit
     patients.



                                              204
9.     Be able to accurately outline the factors            AR, MR         AE
       associated with rehabilitation as they apply to
       initial and early patient care.
10.    Be able to correctly list the indications for, and   AR, MR         AE
       describe the provision of, nutritional support for
       patients sustain trauma.
11.    Be able to correctly identify indications for the
       following basic surgical procedures:
           a.   Laparotomy                                  DSP, AR, DPC   AE, DSP
           b. Debridement of injured tissues                DSP, DPC       AE, DSP
           c. Ultrasound                                    DSP, DPC       AE, DSP
           d. Medical anti-shock trousers (MAST)            DSP, DPC       AE,DSP
           e. HARE traction splint                          DSP, DPC       AE, DSP
           f.   Splinting                                   DSP, DPC       AE, DSP
           g. Diagnostic peritoneal lavage (DPL)            DSP, DPC       AE, DSP
           h. Thoracotomy/throracostomy                     DSP, DPC       AE, DSP
           i.   Hemorrhage control                          DSP, DPC       AE
12.    Be able to list the primary causes/mechanisms
       of injury that contribute to making trauma the
       fifth leading cause of death in those aged 65
       and older:
           a.   Falls                                       AR, GR, MR     AE
           b. Motor vehicle crashes                         AR, GR, MR     AE
           c. Pedestrian injuries                           AR, GR, MR     AE
           d. Burns                                         AR, GR, MR     AE
           e. Domestic abuse                                AR, GR, MR     AE

      C. Interpersonal Skills and Communication

       Principal Education Goals                            Learning       Evaluation
                                                            Activities     Methods




                                               205
1.    Be able to clearly, accurately and succinctly     AR, MR       AE
      present pertinent information to faculty
      regarding patients new to the service including
      newly admitted patients for whom the service
      has been consulted.
2.    Clearly, accurately and respectfully              AR           AE
      communicate with nurses and other hospital
      employees.
3.    Clearly, accurately and respectfully              AR, DPC      AE
      communicate with patients and appropriate
      members of their families identified disease
      processes (including complications), the
      expected courses, operative findings and
      operative procedures.
4.    Maintain clear, concise, accurate and timely      GR, AR       AE
      medical records including (but not limited to)
      admission history and physical examination
      notes, consultation notes, progress notes,
      orders, operative notes and discharge
      summaries.

     D. Professionalism

      Principal Education Goals                         Learning     Evaluation
                                                        Activities   Methods
1.    Be honest with all individuals at all times in    AR, MR, LL   AE, TYPD
      conveying issues of patient care.
3.    Maintain high ethical behavior in all             AR, MR, LL   AE, TYPD
      professional activities
4.    Demonstrate commitment to continuity of care      AR, MR, LL   AE, TYPD
      through carrying out her/his own personal
      responsibilities or through assuring that those
      responsibilities are fully and accurately
      conveyed to others acting in her/his stead.
5.    Demonstrate sensitivity to issues of age, race,   AR, MR, LL   AE, TYPD
      gender and religion with patients, families and
      all members of the health care team.
6.    At all times treat patients, families and all     AR, MR, LL   AE, TYPD
      members of the health care team with respect.
                                              206
7.    Reliably be present in pre-arranged places and           AR, MR, LL    AE, TYPD
      at pre-arranged times except when the resident
      is actively engaged in the treatment of a
      surgical or medical emergency. Under such
      circumstances, the resident should provide
      timely notification to the appropriate
      individual(s) of her/his inability to engage in the
      pre-arranged activity.

     E. Practice-Based Learning and Improvement

      Principal Education Goals                                Learning      Evaluation
                                                               Activities    Methods
1.    Maintain a detailed log of procedures and
      operative cases in which (s)he participates
      including:
          d.   Diagnosis                                       DSP, AP       AE, TYPD
          e. Procedure performed                               DSP, AP       AE, TYPD
          f.   Postoperative course of the patient including   DSP, AP       AE, TYPD
               any complications sustained and an analysis
               of the origin(s) of each complication
2.    Maintain a portfolio of rotation relation literature     AP            AE, TYPD
      searches.
3.    Maintain a portfolio of rotation related formal          AP            AE, TYPD
      presentations including presentation of
      complications (Morbidity and Mortality
      Conference)

     F. Systems Based Practice

      Principal Education Goals                                Learning      Evaluation
                                                               Activities    Methods
1.    Be able to appropriately utilize in a timely and
      cost efficient manor ancillary services including:
          i.   Social Work                                     AR, DPC, MR   AE
          j.   Discharge Planning                              AR, DPC, MR   AE
          k. Physical Therapy                                  AR, DPC, MR   AE

                                                 207
        l.   Occupational therapy                         AR, DPC, MR   AE
        m. Respiratory Therapy                            AR, DPC, MR   AE
        n. Nutrition Services                             AR, DPC, MR   AE
        o. Pharmacists                                    AR, DPC, MR   AE
        p. Physician Extenders including Physicians’      AR, DPC, MR   AE
           Assistants and Nurse Practitioners
3.   Summarize the financial costs, the risks and         AR, MR, DPC   AE
     the benefits of all proposed diagnostic studies
     and therapeutic interventions.
4.   Offer sound justification for all diagnostic tests   AR, MR        AE
     (including laboratory studies) ordered by
     her/him.




                                              208
                                   DERMATOLOGY ELECTIVE

The overall goal of the Department of Dermatology at the University of Texas – Houston is to pursue
excellence in education, research, and patient care in skin disease. Residents need to become
proficient in the six ACGME areas of competence, as summarized in the evaluation form.

The Transitional Year Resident

The Transitional Year Resident will be immediately exposed to the LBJ, HMC and MCACC clinics
just like upper level residents. There will be extremely limited exposure to more difficult inpatient
consultations. They will be exposed to both medical and surgical dermatology.

Goals and Objectives for the Transitional Year Resident
      To gain a general overview of dermatology through a wide variety of clinics and hospital consult
       service.
      To gain an understanding of the approach for evaluating skin lesions.
      To observe the following procedures: skin biopsy, Tzanck smear, KOH preparation, and excisional
       surgery.


  Legend for Learning Activities
  DSP – Directly Supervised    NC – Noon Conferences                 DPC – Direct Patient Care
  Procedures                   BCSC – Basic and Clinical
  JC – Journal Club            Science Curriculum
  M&M-Morbidity & Mortality    CC – Case Conferences
  GR – Grand Rounds            ER – Ethics Rounds


  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                             PR – Peer Review
  PDR–Program Director’s Review (quarterly)              DSP – Directly Supervised Procedures



Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.

A. Patient Care

         Principal Educational Goals                                Learning              Evaluation
                                                                    Activities            Methods

                                                   209
1.     Communicate effectively and demonstrate caring and                   AE
       respectful behavior when interacting with patients      DPC
       and their families
2.     Gather essential and accurate information about their                AE
                                                               DPC
       patients.

B. Medical Knowledge

                                                               Learning     Evaluation
       Principal Educational Goals
                                                               Activities   Methods
1.     Demonstrate evidence of having read about disease                    AE
                                                               DPC
       processes seen in the clinic.
2.     Show progress in being able to use data obtained                     AE
       from the history and examination to formulate an        DPC, DSP
       appropriate diagnosis and plan.
3.     List major differential diagnoses, especially sight                  AE
                                                               DPC, GR
       threatening or life threatening entities
4.     Perform an accurate and complete eye exam on                         AE
                                                               DPC
       patients


C. Interpersonal Skills and Communication

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Use effective listening skills.                          DPC          AE

2.    Work as a team member.                                   DPC          AE

3.    Ask for help when needed.                                DPC          AE

4.    Demonstrate the ability to actively listen to the patient             AE
                                                                DPC
      and answer their questions appropriately.
5.    Demonstrate ability to effectively communicate with the               AE
      patient and family the nature of the disorder, the
      recommended treatment, and alternative treatment DPC
      options, and if the procedures is elective, the elective
      nature of the procedure.
6.    Communicate with the patient in a confidential manner. DPC            AE

7.    Observe and practice effective information exchange                   AE
                                                          DPC
      with patients and their families.
8.    Perform patient counseling in the presence of faculty.   DPC          AE


D.    Professionalism

                                               210
       Principal Educational Goals                             Learning     Evaluation
                                                               Activities   Methods
1.     Demonstrate respect, compassion, and integrity.                      AE
                                                               DPC

2.     Be responsive to the needs of patients and society that              AE
                                                                DPC
       supersedes self-interest.
3.     Be professional and respectful in terms of                           AE
       responsibilities, appearance, communication, interaction DPC
       with patients, staff and ancillary office personnel.
4.     Adhere to high ethics and principles.                    DPC         AE

5.     Demonstrate compassion, kindness, patience and caring                AE
                                                             DPC
       at all times to patients, family, and staff.

E. Practice-Based Learning and Improvement

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Study and evaluate own patient care with faculty input                AE
                                                             DPC
      and discussion.
2.    Utilize evidence-based medicine to better assess and                  AE
                                                             DPC
      adjust patient care.
3.    Participate in discussions in clinic, grand rounds.      GR           AE

4.    Present at Journal Club.                                 JC           AE


F. Systems-Based Practice

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Demonstrate the ability to effectively call on system                 AE
                                                                 DPC
      resources to provide care that is of optimal value.
2.    Practice cost effective health care and resource                      AE
                                                                 DPC
      allocation that does not compromise quality of care.
3.    Demonstrate an understanding of the role of different                 AE
      specialists and other health care professionals in overall DPC
      patient management.




                                                211
                                  NEUROLOGY ELECTIVE
Neurology is a clinical medical specialty. It is defined as a clinical specialty concerned with the
diagnosis and treatment of all categories of disease that affect the nervous system including
the central (brain and spinal cord), peripheral (nerves and roots), and autonomic nervous
systems, their coverings, blood supply, and effectors (muscles). For these nervous system
diseases, the neurologist is the principle care physician and may render all levels of care
commensurate with his or her training.
The structure of the training program is based on supervised clinical work for inpatient
services and outpatient services. A strong educational program of organized instruction in
the basic neurosciences and clinical neurosciences is integrated into the program and
provides balance to the structured rotations for the clinical experiences. The clinical
rotation schedule is designed to provide the transitional year residents in training with
clinical experience and direction from all the designated clinical teaching and supervising
faculty.
Goals and Objectives for the Transitional Year Resident
      Each intern is expected to perform a competent neurological examination.
      Each intern should be able to interpret and recognize common neurological signs.
      Each intern should be able to evaluate and treat patients with common neurological disorders.
      Each intern should be familiar with utilization advantages and limitations of common neurological
       investigative methods.
Responsibilities
      Each intern is expected to write up his assigned patients and be ready to present and discuss them
       with the attending physician or neurology resident.
      Each intern should complete a patient roster list, listing all patients seen with their age and
       diagnosis.
      Each intern should see a minimum of fifteen patients, having done a complete work up on all fifteen.

Educational Materials and Conferences
      Interns are encouraged to read the book Clinical Neurology by Simon, Aminoff, and Greenberg.
       Copies are available at the UT Bookstore. The reading material is supplemented by more detailed
       reading in the neurology sections in current editions of the Textbook of Medicine, Ohara's principals
       of Internal Medicine. We also endorse the current editions of Principles of Neurology by Adams and
       Victor who wish to pursue a more comprehensive textbook devoted to this field of medicine.
      Interns located at Hermann Hospital are required to attend Grand Rounds weekly at noon on Friday.

Educational Opportunities Available to the Transitional Year Resident Include:
      Morning Report 7.044-A/MSB at 8:00 AM at the Medical School (optional).
      Resident Noon Conference at noon 7.044-A/MSB at the Medical School (optional).

Resident Responsibilities for Planning, Record Keeping, Order Writing, and Continuing
Management on the Neurology Service
    The transitional year resident is responsible for daily personal assessment, recording daily
      progress notes, and daily and updated orders on assigned patients.

                                                   212
 Legend for Learning Activities
 DSP – Directly           NC – Noon Conferences              DPC – Direct Patient Care
 Supervised Procedures    BCSC – Basic and Clinical
 JC – Journal Club        Science Curriculum
 M&M-Morbidity &          CC – Case Conferences
 Mortality                ER – Ethics Rounds
 GR – Grand Rounds

 Legend for Evaluation Methods for Residents
 AE - Attending Evaluations                PR – Peer Review
 PDR–Program Director’s Review (quarterly) DSP – Directly Supervised Procedures


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the
six ACGME competencies in the tables below and numbered in the first column. The
second column of the table lists the goal, the third column lists the most relevant learning
activities for that goal, and the fourth column indicates the correlating evaluation methods
for that goal.

      A. Patient Care

         Principal Educational Goals                        Learning           Evaluation
                                                            Activities         Methods
 1.      Communicate effectively and demonstrate                               AE
         caring and respectful behavior when interacting    DPC
         with patients and their families
 2.      Gather essential and accurate information about                       AE
                                                            DPC
         their patients.

      B. Medical Knowledge

                                                            Learning           Evaluation
         Principal Educational Goals
                                                            Activities         Methods
 1.      Demonstrate evidence of having read about                             AE
                                                            DPC
         disease processes seen on the rotation.
 2.      Show progress in being able to use data                               AE
         obtained from the history and examination to       DPC, DSP
         formulate an appropriate diagnosis and plan.
 3.      List major differential diagnoses, especially                         AE
                                                            DPC, GR
         commonly seen neurological diseases.
                                             213
4.      Perform an accurate and complete neurological                         AE
                                                                 DPC
        exam on patients


C. Interpersonal Skills and Communication

                                                                 Learning     Evaluation
        Principal Educational Goals
                                                                 Activities   Methods
1.      Use effective listening skills.                          DPC          AE
2.      Work as a team member.                                   DPC          AE
3.      Ask for help when needed.                                DPC          AE
4.      Demonstrate the ability to actively listen to the patient             AE
                                                                  DPC
        and answer their questions appropriately.
5.      Demonstrate ability to effectively communicate with the               AE
        patient and family the nature of the disorder, the
        recommended treatment, and alternative treatment DPC
        options, and if the procedures is elective, the elective
        nature of the procedure.
6.      Communicate with the patient in a confidential manner. DPC            AE
7.      Observe and practice effective information exchange                   AE
                                                            DPC
        with patients and their families.
8.      Perform patient counseling in the presence of faculty.   DPC          AE


     D.Professionalism

        Principal Educational Goals                              Learning     Evaluation
                                                                 Activities   Methods
1.      Demonstrate respect, compassion, and integrity.                       AE
                                                                 DPC
2.      Be responsive to the needs of patients and society that               AE
                                                                 DPC
        supersedes self-interest.
3.      Be professional and respectful in terms of                            AE
        responsibilities, appearance, communication, interaction DPC
        with patients, staff and ancillary office personnel.
4.      Adhere to high ethics and principles.                    DPC          AE
5.      Demonstrate compassion, kindness, patience and caring                 AE
                                                              DPC
        at all times to patients, family, and staff.

                                                 214
     E.Practice-Based Learning and Improvement

                                                                Learning     Evaluation
        Principal Educational Goals
                                                                Activities   Methods
1.      Study and evaluate own patient care with faculty input               AE
                                                               DPC
        and discussion.
2.      Utilize evidence-based medicine to better assess and                 AE
                                                               DPC
        adjust patient care.
3.      Participate in discussions in clinic, grand rounds.     GR           AE




     F.Systems-Based Practice

                                                                Learning     Evaluation
        Principal Educational Goals
                                                                Activities   Methods
1.      Demonstrate the ability to effectively call on system                AE
                                                                   DPC
        resources to provide care that is of optimal value.
2.      Practice cost effective health care and resource                     AE
                                                                   DPC
        allocation that does not compromise quality of care.
3.      Demonstrate an understanding of the role of different                AE
        specialists and other health care professionals in overall DPC
        patient management.




                                                  215
                                         Pathology Elective

The 1-month elective in the Department of Pathology and Laboratory Medicine is available to
transitional year residents at Lyndon B. Johnson General Hospital and Memorial Hermann Hospital.
 Transitional residents will function mainly as observers but are expected to actively learn and
participate in the service as much as possible.


Goals for the Transitional Year Resident
 To gain an understanding of the role of the surgical pathology service in medical care, including
  intraoperative frozen section consultations.
 To gain experience in handling routine surgical pathology specimens (e.g. gross description,
  evaluation of tumor margins, selection of sections for microscopic examination).
 To become acquainted with the steps involved in the processing of tissue submitted for
  histopathologic examination (i.e. from tissue block to stained slide).
 To become familiar with diagnostic histopathologic criteria for common diseases.
 To become familiar with the essential components of the Bethesda system
 To gain an understanding for the appropriate use of specialized testing, such as
  immunohistochemistry and flow cytometry, in establishing a diagnosis.
 To gain skills in the interpretation of clinical laboratory tests
 To gain exposure to the techniques used in performing clinical laboratory testing
 To recognize the role of the transfusion service in patient care.

Responsibilities of the Transitional Year Resident
 Attend UT pathology department teleconferences daily at 8am in the LBJ or MHH pathology
   residents’ room (refer to posted conference calendar for specific topics)
 Spend at least one week on each of the 3 pathology services (clinical pathology, surgical
   pathology, cytopathology) and the remaining days on whatever service is most relevant to the
   transitional resident’s career interests
 Sit at the microscope to sign out with the residents and attending pathologists on the specific
   service to which you are assigned for the week
 Maintain regular working hours of 8am-5pm within the LBJ or MHH pathology department,
   unless prior approval has been obtained from the chief of pathology
 Observe and assist all fine needle aspiration procedures and bone marrow aspiration/biopsy
   procedures when on the cytopathology service and the clinical pathology service, respectively
 Attend interdepartmental conferences (e.g. tumor board, M&M) in which pathologists are
   presenting cases
 Review glass slide study sets or cases on the website http://www-
   medlib.med.utah.edu/WebPath/webpath.html during free time
 Present a topic of interest as an informal talk or as a powerpoint presentation if so requested by
   the chief of pathology

                                                 216
Evaluation
Transitional residents will be evaluated by the chief of pathology based on their level of
participation, adherence to the above-stated responsibilities, and specific interactions with all
members of the health care team. Evaluations will be in the format provided by the LBJ Transitional
Residency Program Director.


  Legend for Learning Activities
  DSP – Directly Supervised    NC – Noon Conferences                 TF – Teaching Files
  Procedures                   BCSC – Basic and Clinical             AR – Attending Rounds
  JC – Journal Club            Science Curriculum
  M&M-Morbidity & Mortality    CC – Case Conferences
  GR – Grand Rounds            ER – Ethics Rounds

  Legend for Evaluation Methods for Residents
  AE - Attending Evaluations                             PR – Peer Review
  PDR–Program Director’s Review (quarterly)              DSP – Directly Supervised Procedures


Principal Educational Goals by Relevant Competency
The principal educational goals for residents on this rotation are indicated for each of the six
ACGME competencies in the tables below and numbered in the first column. The second column of
the table lists the goal, the third column lists the most relevant learning activities for that goal, and
the fourth column indicates the correlating evaluation methods for that goal.

A. Patient Care

         Principal Educational Goals                                Learning             Evaluation
                                                                    Activities           Methods
 1.      To be respectful of the patient when performing a                               AE
                                                                    DSP
         gross examination.
 2.      Gather essential and accurate information about their                           AE
                                                                    DSP
         patients.

B. Medical Knowledge

                                                                    Learning             Evaluation
        Principal Educational Goals
                                                                    Activities           Methods
 1.     To state the two broad categories of pathology and list                          AE
                                                                DSP
        at least 3 subcategories under each
 2.     To list the criteria for submission of specimens to the                          AE
                                                                DSP
        pathology department (i.e. accept vs. reject specimen)


                                                   217
3.     To give at least one example illustrating the                         AE
       importance of clinical history in rendering a            DSP
       pathologic diagnosis
4.     To perform a gross examination and gross description                  AE
       of at least 5 different biopsy specimens (e.g. gastric
       biopsy) or simple surgical specimens (e.g. fallopian     DSP
       tubes for ligation) under direct supervision of a
       pathology resident
5.     To state at least 3 roles of the frozen section                       AE
                                                                DSP
       procedure in patient care
6.     To describe the fine needle aspiration and bone                       AE
       marrow aspiration/biopsy procedures from start to        DSP
       finish in lay terms
7.     To read at least one complex surgical pathology                       AE
       report and at least one bone marrow aspiration/biopsy    DSP
       report and orally summarize the results
8.     To demonstrate the ability to recognize basic                         AE
       pathology processes under the microscope, including:
        acute inflammation, chronic inflammation,               DSP
       necrosis/gangrene, granulomas, high-grade
       malignancy
9.     To name the major types of red and white blood cells                  AE
       when shown in a peripheral blood smear, and to
                                                                DSP
       provide a differential diagnosis when abnormalities in
       cell number and/or type are detected
10.    To select at least one specific topic per day, based                  AE
       upon current cases encountered, about which to
                                                                DSP
       review basic pathophysiology and diagnostic criteria
       in a general pathology textbook such as Robbins

C. Interpersonal Skills and Communication

                                                                Learning     Evaluation
      Principal Educational Goals
                                                                Activities   Methods
1.    Use effective listening skills.                           AR           AE

2.    Work as a team member.                                    AR           AE

3.    Ask for help when needed.                                 AR           AE




                                               218
D.    Professionalism

      Principal Educational Goals                              Learning     Evaluation
                                                               Activities   Methods
1.    Demonstrate respect, compassion, and integrity.                       AE
                                                               AR

2.    Be responsive to the needs of patients and society that               AE
                                                               AR
      supersedes self-interest.
3.    Be professional and respectful in terms of                            AE
      responsibilities, appearance, communication, interaction AR
      with patients, staff and ancillary office personnel.
4.    Adhere to high ethics and principles.                    AR           AE

5.    Demonstrate compassion, kindness, patience and caring                 AE
                                                            AR
      at all times to patients, family, and staff.

E. Practice-Based Learning and Improvement

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Study and evaluate own diagnostic skills with faculty                 AE
                                                            AR
      input and discussion.
2.    Utilize evidence-based medicine to better assess and                  AE
                                                            AR
      adjust diagnostic skills.
3.    Participate in discussions in clinic, grand rounds.      GR, CC       AE

4.    Present at case at conference at the end of rotation.    CC           AE


F.Systems-Based Practice

                                                               Learning     Evaluation
      Principal Educational Goals
                                                               Activities   Methods
1.    Demonstrate the ability to effectively call on system                 AE
                                                                 AR
      resources to provide care that is of optimal value.
2.    Demonstrate an understanding of the role of different                 AE
      specialists and other health care professionals in overall AR
      patient management.




                                                219
               APPENDIX 1




POLICIES OF THE TRANSTIONAL YEAR PROGRAM




                  220
                                      Transitional Year Program
                             University of Texas-Houston Medical School

                                  Criteria for Eligibility and Selection


Eligibility of Residents

Applicants are considered to be eligible for the Transitional Year program if they are graduates of
any of the following: medical schools in the United States and Canada accredited by the Liaison
Committee on Medical Education (LCME); or colleges of osteopathic medicine in the United States
accredited by the American Osteopathic Association (AOA); or medical schools outside the United
States and Canada (who meet one of the following qualifications: have received a currently valid
certificate from the Educational Commission for Foreign Medical Graduates or have a full and
unrestricted license to practice medicine in a U.S. licensing jurisdiction); graduates of medical
schools outside the United States who have completed a Fifth Pathway program provided by an
LCME-accredited medical school. (I.R., III.A.1.)

Selection of Residents

Applications for the Transitional Year Program are accepted only through the Electronic Residency
Application System (ERAS). Positions are filled through the National Residency Matching Program
(NRMP). Applications are reviewed and evaluated based on educational background, academic
performance, extracurricular activities, letters of recommendation, and a minimum score of 198 on
USMLE Step 1. The Program does not discriminate with regard to sex, race, age, religion, color,
national origin, disability, or veteran status (I.R., III.A.2.) Applicants are invited to interview based
on this assessment. A personal interview is required to be considered for a residency position.
Interviews are conducted by the Program Director and by various faculty members from the
sponsoring and elective departments. Numeric scores are assigned to each interviewee by each
faculty member interviewer. These scores are tabulated, the applicants are ranked, and the rank list
is submitted to the NRMP.




                                                   221
                                      Transitional Year Program
                             University of Texas-Houston Medical School

                                    Policy on Resident Duty Hours

Duty hours are defined by the Accreditation Council for Graduate Medical Education as all clinical
and academic activities related to the residency program, i.e., patient care (both inpatient and
outpatient), administrative duties related to patient care, the provision for transfer of patient care,
time spent in-house during call activities, and scheduled academic activities such as conferences.
Duty hours do not include reading and preparation time spent away from the duty site (P.R., VI.D).

Duty hours must be limited to 80 hours per week, averaged over a four-week period, inclusive of all
in-house call activities.

Residents must be provided with 1 day in 7 free from all educational and clinical responsibilities,
averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour
period free from all clinical, educational, and administrative activities.

Adequate time for rest and personal activities must be provided. This should consist of a 10 hour
time period provided between all daily duty periods and after in-house call.

The objective of on-call activities is to provide residents with continuity of patient care experiences
throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work
day when residents are required to be immediately available in the assigned institution. In-house call
must occur no more frequently than every third night, averaged over a four-week period.

Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents
may remain on duty for up to six additional hours to participate in didactic activities, transfer care of
patients, conduct outpatient clinics, and maintain continuity of medical and surgical care as defined
in Specialty and Subspecialty Program Requirements. No new patients may be accepted after 24
hours of continuous duty.

At-home call (pager call) is defined as call taken from outside the assigned institution. The
frequency of at-home call is not subject to the every third night limitation. Although not currently
part of the program, should at-home call be required, it must not be so frequent as to preclude rest
and reasonable personal time for each resident. Residents taking at-home call must be provided with
1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week
period. When residents are called into the hospital from home, the hours residents spent in-house are
counted toward the 80-hour limit. The program director and the faculty must monitor the demands
of at-home call in their programs and make scheduling adjustments as necessary to mitigate
excessive service demands and/or fatigue. The TYP Institutional Educational Committee is charged
with monitoring compliance on this issue.

                                                   222
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                                   Policy on Resident Supervision



It is the policy of the Transitional Year Program that all residents will be supervised by qualified
faculty while providing patient care, and that residents will be provided with rapid, reliable systems
for communicating with supervising faculty.

The teaching staff will supervise the resident in a manner designed to provide residents with
progressive responsibility for patient management. The level of responsibility or independence given
to the resident by the supervising physician for the care of patients will depend on the resident’s
knowledge, manual skills, experience, and complexity of the patient’s illness, and the risk of
procedures that residents perform.

More senior residents may supervise residents; however, all patient care and resident supervision
ultimately is the responsibility of the faculty attending physician.

Attending physicians or senior residents with experience appropriate for the severity and complexity
of a patient’s condition will be available at all times on site.

Faculty and residents must be educated to recognize the signs of fatigue and to apply policies to
counteract the potential negative effects (P.R., VI, C). Residents must take responsibility for
reporting to the Program Director when they are under excessive stress or are fatigued to the point
that patient care may be compromised, so that the Program Director can take appropriate action. See
Policy on Resident Well-Being on page 196 of this manual.




                                                  223
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                 Policy on Resident Corrective Action, Complaints and Grievances


Academic and Corrective Action

If, based on the evaluation process, a resident is not performing satisfactorily; the Program Director
will document the deficiencies, outline a plan to correct deficiencies, and communicate this
information to the resident and to the Transitional Year Education Committee. If the unsatisfactory
performance continues, the Program Director may take appropriate action including remedial
assignments, probation, suspension, or dismissal from the Program. Should the unsatisfactory
performance constitute a threat to patient safety, the Program Director may immediately suspend the
resident pending further action.

The Policy Review Committee is available to the resident to review instances of suspension or
dismissal.

Additional Corrective Actions

In cases of alleged scholastic dishonesty, theft, or conduct prohibited by UT Health Science Center
policy, local, state, or federal law; the Program Director may terminate the resident’s appointment
pending an inquiry. Such inquiry will be conducted in a manner consistent with the process outlined
in the Graduate Medical Education Resident Handbook, Section I.Q.2

Resident impairment due to substance abuse is handled in accordance with the Graduate Medical
Education Committee’s Resident Impairment Policy.

Instances of sexual harassment are handled in accordance with the UT Health Science Center policy
as stated in the Handbook of Operating Procedures, Section 2.04

Dismissal

A resident’s appointment may be terminated prior to the end of the appointment term due
to academic dismissal or for cause as described above, and/or whenever the Program
Director determines that the resident constitutes a threat to patient safety. A resident so
terminated will continue to be compensated until the end of the appointment term, or for
3 months from date of termination or until all appeals are exhausted and a final decision
is rendered, whichever comes first.



                                                 224
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                                    Policy on Resident Well-Being


The Transitional Year Program is committed to establishing an environment that is optimal for both
resident education and for patient care, while ensuring that undue stress and fatigue of residents is
avoided.

The Program Director and faculty are charged with monitoring resident stress, including mental or
emotional conditions inhibiting performance or learning and drug- or alcohol-related dysfunction.
They recognize the need for timely provision of confidential counseling and psychological support
services to residents. Training situations that consistently produce undesirable stress on residents
will be evaluated and modified (P.R., IV.B.5.) Residents experiencing difficulty may obtain
assistance through the Employee Assistance and Work/Life Programs, and through the Resident
Mental Health Consultation Service (see Graduate Medical Education Resident Handbook, Section
II. H. 11-12).

Impaired resident (i.e., drug- or alcohol-related dysfunction) and related allegations will be handled
in accordance with the GME Committee’s Resident Impairment Policy (see Graduate Medical
Education Resident Handbook).




                                                  225
                                    Transitional Year Program
                           University of Texas-Houston Medical School

                                  Policy on Resident Moonlighting


The Transitional resident is prohibited from engaging in professional activities outside the
educational program (moonlighting). Under Texas law, professional activities involving the practice
of medicine outside the program are available only to a resident who holds a medical license from
the Texas State Board of Medical Examiners. An institutional permit does not entitle the resident to
assume professional activities outside the Educational Program. Since, in most cases, the
Transitional resident works under the provisions of an Institutional Permit issued by the Texas State
Board of Medical Examiners, s/he is prohibited from working as a physician outside the educational
realm.

Should the circumstance occur that a Transitional resident holds a medical license from the Texas
State Board of Medical Examiners (or wishes other outside employment), any moonlighting activity
must be approved by the Program Director.

Because of the Program’s commitment to ACGME duty hour regulations, internal moonlighting
(moonlighting that occurs within UT-Houston programs and which counts toward the 80-hour
weekly limit on duty hours) will not be permitted.




                                                226
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                   Policy on Evaluation, Termination and Resignation of Residents


Evaluation of residents

Residents will be evaluated by the attending physician at the end of each month's rotation as to their
knowledge, skills and professional growth. In September, December, March, and June, each resident
will meet with the Program Director for a performance evaluation. This evaluation will be based on
the previous three months’ input from attending physicians as well as the resident's input and will be
provided to the resident in writing. Progress reports will also be sent to your PG2 Program Director
as mandated by the ACGME. In those instances of an "Unsatisfactory" rating of the resident’s
overall clinical competence, no credit will be given and the rotation will be repeated. If a resident
receives two or more overall evaluations in the “marginal” range (rated 3 or 4), appropriate
remediation will be determined by the Program Director.

The resident must attain evaluations on all rotations of “satisfactory” or higher in all categories. Any
resident attaining one or more unsatisfactory ratings will be counseled by the Program Director.
Subsequent rotation evaluations must show improvement to the satisfactory level in the evaluation
scores in the deficient category(s). Isolated ratings of unsatisfactory, although requiring counseling,
will not necessarily prohibit the resident from completing the transitional year; however, repeated
unsatisfactory ratings may require remediation by the resident at the discretion of the Program
Director.

Two one-month rotations in which the resident receives an overall unsatisfactory rating will require
an additional month of remediation beyond the normal completion date of the residency. More than
two overall unsatisfactory ratings will require additional remediation and/or dismissal from the
residency at the discretion of the Program Director. Dismissal will require the consent of the
Transitional Year Education Committee, and will be handled in accordance with the policies
established by the Graduate Medical Education Committee.

A final written evaluation for each resident will be prepared by the Program Director which will
include a review of the resident’s performance during the last quarter of the training year, as well as
the Program Director’s assessment of the resident’s professional ability to advance into a categorical
program.

All evaluations will be maintained on file in the Program Office. Each resident will have access to
his/her own file throughout the year and may review its contents in the Program Office P.R.,
V.A.1.c.


                                                  227
Termination of residents

A resident’s appointment may be terminated prior to the end of the appointment term due to
academic dismissal as described in section II.Q.1. of the Graduate Medical Education Resident
Handbook or for cause as described in section II.R.3. and /or whenever the Program Director
determines that the resident constitutes a threat to patient safety in accordance with sections II R.1. or
II. R.2. A resident so terminated will continue to be compensated until the end of the appointment
term, or for 3 months from date of termination or until all appeals are exhausted and a final decision
is rendered, whichever comes first.

Resignation

A resident may resign from the Program with thirty (30) days written notice of his or her intent to
resign. The resident’s resignation must be submitted to the Program Director and/or department
chairperson. All conditions of appointment will terminate on the effective date of the resignation.

Grievances

Fair policies and procedures exist within U.T. Graduate Medical Education to address resident
grievances and due process in compliance with the ACGME Institutional Requirements. Grievances
may involve payroll, hours of work, working conditions, clinical assignments, issues related to the
program or faculty, or the interpretation of a rule, regulation, or policy. A resident who has a
grievance should first attempt to resolve it with the Program Director. Should the grievance not be
satisfactorily addressed, the resident may submit a written grievance to the Policy Review
Committee, which committee will review the grievance, make a decision, and communicate that
decision to the resident and other involved parties. The details of this process appear in Graduate
Medical Education Resident Handbook, Section II. N




                                                   228
                                      Transitional Year Program
                             University of Texas-Houston Medical School

                                    Policy on Conference Attendance

All sponsoring departments of the Transitional Year Program will provide planned educational
experiences that will include: morning report, morbidity and mortality conferences; journal club;
seminars; presentation of specialty topics, and grand rounds (P.R.IV. A.5.b.5.).

Attendance by Transitional residents is mandatory and will be monitored and documented. Each
sponsoring department will submit conference attendance reports to the Transitional Year Program
Office. Conference attendance will be an element of the performance review conducted by the
Program Director.

It is the responsibility of the resident to report to the Program Director any clinical settings that
preclude the resident’s attendance at conferences.

Additionally, Transitional residents attendance is mandatory at Lunch & Learn unless you are post
call or on vacation. TY residents are required to sign an attendance sheet and participate in all
learning activities.




                                                   229
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                                  Policy on Use of Vacation Time


By contract, Transitional residents are given 14 days of paid vacation leave. It is the policy of the
Transitional Year Program that this vacation may be scheduled over a maximum of two periods, to
include time off for interviews. No vacation may be taken during the month of June. Vacation is
also prohibited while on certain rotations. These rotations include elective rotations, IM Adult ER,
IM Wards, IM ICU, IM CCU; Pedi NICU, and TY General AMB. Since this list is subject to the
dictates of the sponsoring departments, it is recommended that you consult with the Program
Coordinator before committing to vacation plans. Approved vacations are published as part of the
resident's rotation schedule. If a change to the published schedule becomes necessary, the resident
must make the request to the Transitional Year Program Office by completing a Vacation and Leave
of Absence Request form.

All requests are to be scheduled through the Transitional Year Program Office, not through the office
of a sponsoring program or by permission of an attending faculty member. Any vacation request
approved by someone other than the Transitional Year Program Director will not be honored.




                                                 230
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                       Policy on Additional Leave for Health Related Reasons

Should a transitional resident have a health issue that requires an absence in excess of available paid
leave, the following guidelines will apply:

   1. A licensed physician must document the health issue.

   2. All available sick time and vacation time will be allocated to the period of illness.

   3. Should the absence exceed the balance of available paid leave, an additional period of unpaid
      leave of absence may be granted by the Program Director, up to a maximum of six weeks
      (paid and unpaid combined).

   4. Absences in excess of six weeks will require action by the Transitional Year Education
      Committee to determine whether:
      a. the period of residency training will be extended in order for the resident to satisfactorily
      complete the requirements; or
      b. the resident will be terminated from the program.




                                                  231
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                       Policy on Use of Pagers and Electronic Communication


Pagers

Alphanumeric pagers are provided for each resident. Residents are required to carry their pagers at
all times, except when on vacation, and are required to respond to pages in the shortest time-frame
possible.

Electronic Mail

Because of the use of electronic evaluations, residents are required to have a University of Texas e-
mail address and to use it in preference to a private e-mail service for communication related to the
training program. The UT e-mail service may NOT be forwarded to a private e-mail service.

The Transitional Year Program Office utilizes pagers and e-mail as the primary means of
communicating with residents. Therefore, residents must regularly check and respond to messages
received through these media.




                                                 232
                                     Transitional Year Program
                            University of Texas-Houston Medical School

                              Policy on Use of Personal Digital Assistant

Equipment

All Transitional Year residents are required to have a personal digital assistant (PDA) for use during
the training year. Limited software chosen by the Program Director in conjunction with the resident
and related to professional activities also will be provided. Additional software desired by the
resident will be at the individual’s expense.

Use of PDA

The PDA is required to facilitate the resident’s access to clinical information, resident’s rotation and
on-call schedules, and patient care activity, as well as other educational functions. The resident is
cautioned to keep the PDA properly charged. A failure of the batteries will result in the loss of all
stored information and software.




                                                  233
                     POLICY ON APPROPRIATE STUDENT TREATMENT
                       The University of Texas Medical School at Houston


   I.      Standards for Conduct in the Teacher-Learner Relationship

The academic environment, particularly in medical education, requires civility from all participants,
regardless of role or level, and a particular respect for the values of professionalism, ethics, and
humanism in the practice of medicine.

The relationship between teacher and learner is based on mutual respect and trust. Faculty must
respect students’ level of knowledge and skills, which students have the responsibility to represent
honestly to faculty. Faculty are obligated to evaluate students’ work fairly and honestly, without
discrimination based on gender, ethnicity, national origin, sexual orientation, or religious beliefs.
Faculty have a duty not only to promote growth of the intellect but at the same time to model the
qualities of candor, compassion, perseverance, diligence, humility, and respect for all human beings.


Because this policy and document pertains to students as learners, references to teachers and faculty
also include residents and fellows in their teaching and supervisory role with regard to students.

Examples of behavior that are unacceptable at The University of Texas Medical School at Houston
include:

              Physical or sexual harassment or abuse
              Discrimination or harassment based on race, gender, age, ethnicity, religious beliefs,
               sexual orientation, or disability
              Speaking in disparaging ways about an individual including humor that demeans an
               individual or a group
              Sending students on inappropriate errands
              Loss of personal civility: shouting, displays of temper, publicly or privately abusing,
               belittling, or humiliating a student
              Use of grading or other forms of evaluation in a punitive or retaliatory manner

Students are also expected to maintain the same high standards of conduct in their relationships with
faculty, residents, support staff, and fellow students.

   II.     Procedures for Reporting and Investigating Violations

Students enrolled in the Medical School (or Medical School portion of the M.D./Ph.D. program)

                                                 234
should report abuse or mistreatment to the Associate Dean for Student Affairs. The Associate Dean
for Student Affairs will meet with the student to discuss the incident or behavior and the options for
action.

UTHSC-Houston policies and procedures concerning misconduct by faculty and staff, including
sexual and physical abuse and harassment, are outlined in the Handbook of Operating Procedures
(HOOP). The Rules and Regulations of the Board of Regents (“Regents’ Rules”) contain
provisions for student misconduct, including misconduct against fellow students. The Associate
Dean for Student Affairs will advise and assist the student in following applicable procedures of the
institution.

In the event there is no applicable existing procedure, the Associate Dean for Student Affairs in
consultation with the student will determine the most appropriate plan of action. This may involve
an investigation by the Associate Dean for Student Affairs to establish the facts while respecting the
rights and confidentiality of the involved parties.

Depending on the nature or scope of the reported mistreatment, the Associate Dean for Student
Affairs has the authority to appoint an ad hoc Committee on Student Treatment consisting of three
faculty members, one of whom will be appointed to chair the committee. An attorney from the
UTHSC-H Office of Legal Affairs and Risk Management will serve as an ex officio member of the
Committee to insure that University and Health Science Center policies and procedures are followed.
 The purpose of the ad hoc Committee will be to investigate the complaint, establish facts respecting
the rights and confidentiality of the involved parties, and recommend a course of action to the
Associate Dean for Student Affairs.

It will be made clear from the fact-finding or investigation stage forward and through final
disposition of the report that retaliatory behavior or reprisals of any kind will not be tolerated.

The Committee on Student Treatment will be required to report its findings in writing within thirty
days of its constitution to the Associate Dean for Student Affairs.

If, following determination of the facts and considering the recommendation of the ad hoc
Committee on Student Treatment, if one was appointed, the Associate Dean for Student Affairs may
take one or more of the following actions in consultation with the Office of Legal Affairs and Risk
Management:

      Arrange mediation between the parties
      Report findings and recommendations to the perpetrator
      Report findings and recommendations to the Dean
      Report findings and recommendations to the perpetrator’s department chair
      Report findings and recommendations to the faculty member in charge of the course,
       clerkship, or elective in which the mistreatment took place
                                                 235
         In the event the perpetrator is a resident, report findings and recommendations to the
          residency program director and Associate Dean for Educational Programs

These actions may be in addition to or superseded by actions taken by the appropriate bodies or
individuals if specific UTHSC-H procedures (for example, the Policy on Sexual Harassment) are
followed.

   III.      Dissemination and Education

In order to make sure that faculty, residents, fellows, and students are aware of the Policy on
Appropriate Student Treatment, several mechanisms for dissemination will be used.

The Policy will be added to the Medical School website on the principal students, faculty, and house
staff web pages.

A hard copy of the Policy will be given to current house staff and fellows and given to new house
staff during orientation.

A hard copy of the Policy will be given to current students and thereafter to entering students at
orientation. It will be reviewed and discussed at Orientation and later in the fall semester meetings
of the Master Advisory groups.

A hard copy of the Policy will be given to faculty and distributed at faculty orientations. Chairmen
and Directors will be responsible for seeing that the Policy is made known to their faculty and
discussed at departmental/division meetings.

Each course director, clerkship director and residency director will be responsible for seeing that the
Policy is made known to their teaching faculty and to all students at the start of each course,
clerkship or rotation.




                                                    236
   APPENDIX 2




EVALUATION FORMS




      237
                   Program Director Quarterly Rating of Resident Clinical Competence
COMPONENTS and RATINGS                                                      PGY 1
Patient Care
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Medical Knowledge
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Practice-Based Learning
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Interpersonal and Communications Skills
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Professionalism
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
System-Based Learning
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Overall Clinical Competence
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
Performance Compared to Categorical Peers
      Satisfactory                                   Full credit
      Marginal (rated 3 or 4)                        Full credit for one marginal
                                                     If > 2 marginals, remediation as defined
                                                     by Program Director
      Unsatisfactory                                 No credit. Repeat rotation
                                                 238
Please scroll down to find the attending’s name. If the attending assigned to you is incorrect,
contact Debbie Tabor and DO NOT fill out the evaluation until the correct attending is assigned
to you.

You must finish this form in one sitting. It will time out in 20 minutes. If you fail to submit before
then, all data will be lost.

                                        Transitional Year Program
                                        Rotation Evaluation Form

Date:                                    Rotation:
Resident’s Name:                         Rotation Period:

Clinical Experiences
        Patient diversity                N/A        Poor         Adequate    Excellent
        Workload                         N/A        Too light    Too heavy   Optimal
        Resident responsibility          N/A        Not enough   Too much    Optimal
        Appropriate supervision          N/A        Not enough   Too much    Optimal
        Hospital ancillary services      N/A        Poor         Adequate    Excellent

Equivalence of Experience
        Experience equal to that of categorical residents       Yes           No
        If No, provide specifics: _______________________________________________________

Educational Content (Scale 1 = worst to 5 = best)
        Educational goals
                 Clearly stated          N/A        1      2     3      4    5
                 Met                     N/A        1      2     3      4    5
        Structure of curriculum          N/A        1      2     3      4    5
        Teaching rounds                  N/A        1      2     3      4    5
        Ambulatory experiences           N/A        1      2     3      4    5
        Problem Based Learning           N/A        1      2     3      4    5
        Educational conferences          N/A        1      2     3      4    5
        Adequate reading/study time      N/A        1      2     3      4    5

Overall Educational Quality of Rotation
                                         Poor       Mediocre     Good        Excellent




                                                        239
USEFUL TELEPHONE NUMBERS

ADMINISTRATIVE
                 Transitional Year Program Office              713-566-4658
                 Debbie Tabor, TYP Residency Coordinator

                 Program Director                              713-566-5775
                  Christine E. Koerner, TYP Program Director

                 Chief of Staff Office

                 Administrative Services Officer               713-566-4646

                 Graduate Medical Education Office - UT        713-500-5151
                  Paula Ramsay: Loan Deferments
                  Joan Garza: Licensure

                 House Staff Affairs- Hermann Hospital         713-704-4298

                 Legal Affairs-UT                              713-500-3280
                  Catherine Thompson, RN, MPH
CLINICAL
                 Anesthesiology/STICU                          713-500-6271
                  Jonetha Davidson, MD, Rotation Coordinator

                 Dermatology                                   713-500-8330
                  Robert Jordan, MD, Rotation Coordinator
                  Irene Morales, Rotation Secretary

                 Emergency Center--Adult/LBJ                   713-566-5397
                  Richard Robinson, MD, Chief

                 Emergency Center--Pediatrics/LBJ              713-566-5775
                  Christine Koerner, MD, Chief

                 General Surgery/LBJ                           713-566-5095
                  Tien Ko, MD, Chief
                  Monique Nunley, Senior Staff Assistant

                 General Surgery/HH                            713-500-7237
                  John Potts, MD, Program Director
                  Kathalyn Gonzalez, Residency Coordinator
                                         240
                     Internal Medicine                                713-500-6525
                      Susan Jones, Admin. Residency Coordinator
                      Phyllis Martin, Residency Coordinator           713-500-6526
                      Charity Harbes, Residency Coordinator           713-500-6536
                      Kim Concepcion, Residency Coordinator (LBJ)     713-566-4550

                     Neurology                                        713-500-7024
                      Renee Tagert, Rotation Secretary

                     Obstetrics & Gynecology/LBJ                      713-566-5735
                      Kimberly Leatherwood, Residency Coordinator

                     Ophthalmology                                    713-500-6004
                      Judianne Kellaway, MD, Rotation Coordinator
                      Saultczy Bleu, Rotation Secretary

                     Pathology                                        713-500-5402
                      Margaret Uthman, MD, Program Director
                      Amy Garza, Residency Coordinator

                     Pediatrics/LBJ                                   713-566-5845
                      Norma Alonso, Departmental Secretary

                     Pediatrics/HH                                    713-500-5800
                      Shirlene Edwards, Residency Coordinator

                     Radiology/LBJ                                    713-566-5538
                      Chitra Chandrasekhar, MD, Assistant Professor
                      Hilda Petter, Staff Assistant

                     Radiology/HH                                     713-500-7643
                      Sandra Oldham, MD, Program Director
                      Lea Roberts, Rotation Coordinator

Employee Assistant Program                                            713-500-3327

Work Life Program                                                     713-500-3327

Student Health Office                                                 713-500-5171
       Needle stick, exposure hotline                                 B 713-951-8013


                                              241
The University of Texas Medical School at Houston
                TRANSITIONAL YEAR PROGRAM MANUAL


                                     2010-2011
                               Christine E. Koerner, MD
                                  Program Director

                                    Debbie Tabor
                                 Program Coordinator



Participating Hospitals:
       Lyndon B. Johnson General Hospital
       Memorial Hermann Hospital
       UT MD Anderson Cancer Center




                          I acknowledge receipt of this Manual


                  ________________________________________________
                      Name                                Date




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