Toronto Western Hospital Objectives PGY5/6

Rotation-Specific Objectives for Neurosurgical Residents on Neurosurgical Services:
Chief Rotation at Toronto Western Hospital

Toronto Western Hospital
The Neurosurgery service at the Toronto Western Hospital (TWH) is the largest in Canada. This service distinguishes itself by providing tertiary and quarternary neurosurgical care to patients with complex neurosurgical conditions affecting the brain and spine. Unique features of the Neurosurgery service at TWH include a combined neurosurgical and orthopedic spinal program, multidisciplinary programs for patients with AVMs and aneurysms, movement disorders and degenerative brain diseases, brain tumors, and epilepsy. Other areas of expertise and focus include intra-operative navigation and imaging, awake craniotomy for brain tumors with cortical mapping, endovascular therapy for aneurysms and AVMs, and stereotactic radiosurgery for tumors and vascular malformations using the Gamma Knife unit.

Residents typically rotate as junior (PGY1-3) and then as Chief (PGY5-6) residents at TWH for periods up to 6 months. Throughout their rotations at TWH, residents learn a wide variety of procedures to care for patients with complex neurosurgical conditions.

MEDICAL EXPERT

KNOWLEDGE: At the completion of their rotation, the Chief resident will be able to:

• A complete understanding of the main acquired adult neurosurgical disorders requiring neurosurgical attention including infectious diseases, head and spinal cord injury, brain tumours, stroke, vascular malformations, and degenerative diseases of the brain and spinal cord.
• A detailed knowledge of the anatomy of the central and peripheral nervous systems, including the spine and skull, and a working basic knowledge of the other disciplines including physiology, pathology, endocrinology, and neuropsychology.
• Familiarity with and understanding of diagnostic imaging studies used to investigate the patient with a neurosurgical disorders including EEG, EMG, CT, MRI, MEG, and ultrasound.
• A comprehensive understanding of the spectrum of neurosurgical procedures that are available for the treatment of the patient with neurosurgical disease.

CLINICAL SKILLS: At the completion of their rotation, the Chief resident will be able to:

• The ability to obtain a detailed history and perform a complete neurological examination in the patient in order to provide a differential diagnosis and localization of diseases affecting the central nervous system.
• The demonstration of skills in interpreting appropriate general diagnostic tests (hematology, x-ray, chemistry, etc.) for the satisfactory management of patients.
• The provision of comprehensive ongoing post-operative neurological assessment and care, including neuro-intensive care, to the neurosurgical patient.
• A superior ability to interpret neuroradiological examinations of patients with all types neurosurgical disorders.

TECHNICAL SKILLS: At the completion of their neurosurgical rotation, the Chief neurosurgery resident at TWH will have demonstrated a thorough understanding of neurosurgical anatomy, and the technical ability to satisfactorily and safely perform the following procedures:

• Ventriculostomy including endoscopic third ventriculostomy
• Burr holes for drainage of subdural hematomas
• Insertion of ICP monitor
• Craniotomy for traumatic head injuries including extradural hematoma, subdural hematoma, intracerebral hematoma, depressed skull fractures and basal skull fractures, and lobectomy
• Craniotomy for tumour including intradural removal of primary and metastatic tumours, and tumours in the posterior fossa
• Awake craniotomy for tumor removal
• Posterior fossa craniotomy for acoustic schwannoma, trigeminal neuralgia and hemifacial spasm
• Craniotomy for clipping of intracranial artery aneurysms
• Craniotomy for excision of AVMs and cavernous malformations
• Transphenoidal resection of pituitary tumours
• Lobectomy for epilepsy
• Craniotomy for invasive monitoring for epilepsy including depth electrodes
• Utilization of image guidance (neuronavigation)
• Posterior fossa decompression for Chiari malformation
• Carotid endarterectomy
• Performance of stereotactic brain biopsy
• Cranioplasty
• Repair CSF leak
• VP shunt insertion and shunt revision
• Application of Halo ring and use of cervical spinal traction
• Laminectomy, decompression and fusion of spinal fracture with instrumentation as required
• Laminectomy for cervical, thoracic, and lumbar degenerative disc disease
• Laminectomy for epidural metastatic disease and other spinal tumours including intamedullary spinal cord tumours
• Carpal and ulnar tunnel decompressions

Under the supervision of the staff neurosurgeon, the Chief resident at TWH will assist at various levels in the completion of the following complex procedures:

• Supratentorial and infratentorial craniotomy for complex skull base lesions
• Craniotomy for complex aneurysm repair or AVM excision
• Treatment of pain (including dorsal column/deep brain stimulation), and epidural infusion of analgesics
• Radiosurgery for arteriovenous malformations and tumours
• Stereotaxic surgery for movement disorders such as Parkinson's disease and other functional neurosurgery.

COMMUNICATOR: At the completion of their rotation, the resident will be able to:

• Prepare written documentation regarding patient interactions in a timely and accurate fashion, including, consultations, progress notes, discharge notes, and operative notes.
• Obtain informed consent for all major neurosurgical procedures, including full disclosure of relevant indications, risks, benefits, and alternatives.
• Communicate effectively with patients and families when disclosing bad news and medical errors.
• Establish communication with the patient and family that supports a trusting and open relationship.
• Respond appropriately to patients, families, and colleagues, who express anger, hostility, or a complaint.
• Communicate in a clear, concise and collegial manner with other health care professionals.
• Communicate to a group of peers or allied health personnel in a clear and understandable way at weekly conferences
• Communicate effectively with nursing managers and administrators to express the needs of the clinical service.

COLLABORATOR: At the completion of their rotation, the resident will be able to:

• Effectively and respectfully collaborate with other physicians, health care professionals, and community agencies to contribute effectively to interdisciplinary team activities.
• Listen to concerns expressed by others providing care and assist in resolving these concerns if appropriate.

LEADER: At the completion of their rotation, the resident will be able to:

• Demonstrate time management for clinical activity, learning needs and personal activities.
• Prioritize clinical activities in a manner to optimize patient care and the functioning of the clinical service.
• Triage patients and identify neurosurgical emergencies that require prompt and immediate management including evaluating appropriate diagnostic and imaging modalities and plan for operative treatment.
• Delegate responsibilities where and when appropriate.
• Direct the complete care of a group of patients on the service by delegating responsibilities to other members of the team including junior residents and nurse practitioners.

HEALTH ADVOCATE: At the completion of their rotation, the resident will be able to:

• Identify the important determinants of health that affect their patients.
• Support the health of patients/families by providing appropriate referrals, support and information on health maintenance, as well as community/home resources.
• Intervene on behalf of patients or the community with respect to the social, economic and biologic factors that may impact on the patients’ health.
• Effectively advocates for practices that enhance health and well-being.
• Demonstrate sensitivity to the needs of patients and their families as they are affected by age, gender, cultural and ethnic perspectives.

SCHOLAR: At the completion of their rotation, the resident will be able to:

• Maintain and enhance professional activities through ongoing learning.
• Critically evaluate medical information and its sources, apply this appropriately to practice and communicate this at weekly rounds.
• Engage in academic projects with a view to presentation at national/international meetings and publication.
• Supervise and teach medical students, junior residents, and off-service rotating residents.

PROFESSIONAL: At the completion of their rotation, the resident will be able to:

• Deliver the high quality care with integrity, honesty and compassion.
• Fulfill medical, legal, ethical and professional obligations of the specialist.
• Meet deadlines, be punctual, monitor patients, and provide follow-up.
• Demonstrate an understanding of the principles of ethics and apply these in clinical situations.
• Demonstrate self-assessment, seek and accept advice when necessary.
• Maintain and complete a procedural case log that accurately reflects the resident’s surgical experience