OTOLARYNGOLOGY SUBSPECIALTY ROTATION SPECIFIC GOALS AND OBJECTIVES

EDUCATIONAL GOALS & OBJECTIVES: HEAD AND NECK

PGY 1 residents spend a portion of their first year Otolaryngology rotation (approximately 2 weeks) on the Head and Neck service. During the PGY 2 year residents complete a 2 month rotation on the head and neck service as the designated "head and neck junior” resident. An additional 2 month rotation is completed during the first 6 months of the PGY 2 year as a split rotation where weekly duties are divided between the head and neck service and the pediatrics service. On designated pediatric clinic and OR days this resident’s responsibilities will be to the pediatric service, while on other days he or she will participate in head and neck operative cases or head and neck attendings’ private clinics. This “pedi-HN” resident will not participate in the Thursday head and neck staff clinic at Jackson Memorial Hospital (JMH). This conflicts with pediatric service responsibilities, but he or she will round on the head and neck inpatient service on a daily basis during the week. PGY 2 residents will participate in the Thursday JMH head and neck clinic on a weekly basis when they rotate on the service as the head and neck junior. PGY 3 residents will complete a 2 month rotation as the designated head and neck junior on months when this slot is not filled by a PGY 2 resident. PGY 4 and 5 residents will complete a total of 3 months on the head and neck service during each year. Two of these months will be spent as the Chief of the service, while one will be spent as the senior resident who is not the overall service chief but who has primary responsibility for the inpatient head and neck service at the University of Miami Hospital (UMH). This is primarily an organizational point, as the head and neck senior resident may participate in operative cases or clinics at JMH and the University of Miami Hospital and Clinics / Sylvester Comprehensive Cancer Center (UMHC/Sylvester), just as the head and neck Chief resident will participate in operative cases at UMH.

The Head and Neck service has responsibility for all head and neck patients at Jackson Memorial Hospital (JMH), the University of Miami Hospital/Sylvester Comprehensive Cancer Center (UMHC/Sylvester), and the University of Miami Hospital (UMH), providing opportunities for comprehensive inpatient and outpatient management of indigent and private patients with head and neck neoplasms. All private patients with head and neck tumors are evaluated in the outpatient clinics of the Sylvester Comprehensive Cancer Center. Their long term follow-up continues in the private attending clinics at the Cancer Center. Indigent patients with head and neck tumors are evaluated in the Head and Neck Clinic at Jackson Memorial Hospital. Resident participation in the attending private clinics at the Sylvester Comprehensive Cancer Center is strongly encouraged. The indigent head and neck clinic at Jackson Memorial Hospital operates under the direct on-site supervision of Elizabeth Franzmann, MD, one of the head and neck attendings. All patients seen in the indigent clinic are evaluated by

residents, with medical decision-making and administrative management of these patients directed by the chief resident of the head and neck service in consultation with the head and neck attending. Indigent patients requiring surgery are all operated upon at Jackson Memorial Hospital. Private patients evaluated in the Sylvester Cancer Center clinics may be operated upon at any of the three institutions (Jackson Memorial, University of Miami Hospital and Clinics/Sylvester, University of Miami Hospital) depending upon operating room availability and medical comorbidities. Continuity of care is insured by resident participation in both indigent and private clinic settings in new patient evaluation and work-up, in the multidisciplinary head and neck tumor conference where patients from both the indigent and private clinics are discussed, participation in the surgical and inpatient care of these patients regardless of the institution where their surgery is performed, and finally in their long-term follow-up of these patients in the outpatient clinics. The inpatient care of all head and neck patients at Jackson Memorial Hospital, and the University of Miami Hospital, and the University of Miami Hospital and Clinics/Sylvester Comprehensive Cancer Center is managed by residents on the head and neck service with input from the head and neck fellows and under the supervision of the head and neck attending responsible for that patient’s care. The residents have equal opportunities and responsibilities for the operative care of both indigent and private patients at each hospital. Similarly, all inpatients are managed by the resident members of the head and neck team irrespective of their funding status. Other head and neck experience is gained during two month rotations at the VA hospital during the PGY 2 year of training.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the head and neck rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning

Residents begin their head and neck experience mastering the fundamentals of the head and neck examination and outpatient procedures such as fiberoptic

laryngoscopy and fine needle biopsy. These concepts and techniques are introduced in the PGY 1 year and mastered in the PGY 2 year. Surgical skills initially are gained as first and second assistant on major head and neck surgical procedures. This provides opportunities to learn proper tissue handling skills, fundamentals of skin flap elevation, principles of hemostasis and surgical knot tying. Importance of exposure is learned through proper retraction. The role of surgeon is first taught with direct faculty and senior resident supervision on basic surgical procedures including tracheotomy, endoscopy, and submandibular gland excision. More advanced surgical procedures are introduced after competencies are demonstrated on basic procedures as surgeon, and after adequate experience have been gained as assistant on these procedures. Faculty review resident case logs to assess areas of weakness and constantly assess individual surgical skills on a very busy operative rotation. Senior residents gain valuable perspective as teaching assistant on straightforward procedures while mastering more advanced techniques as surgeon. While all residents participate in the care of head and neck patients regardless of residency level, the following clinical and procedural competencies are expected to be mastered by each PGY level.

PGY1: Head and neck examination, fiberoptic laryngoscopy, feeding tube placement, surgical drain management, identification of causes of wound infection or breakdown, orotracheal intubation, familiarity with surgical instrumentation and nomenclature, fine needle biopsy, tracheotomy, upper rigid endoscopy.

PGY2: Head and neck examination, fiberoptic laryngoscopy, feeding tube placement, surgical drain management, management of wound complications (including fistula, flap necrosis, and major vessel bleeding), open and needle biopsy, upper rigid surgical endoscopy, submandibular gland excision, tracheotomy, cervical node biopsy, neck dissection, split skin graft.

PGY3: Neck dissection, parotidectomy, thyroidectomy, laryngectomy, composite resections, pectoralis flap harvest.

PGY4: Conservation laryngectomy, endoscopic laser resection, greater emphasis on primary tumor resection, craniofacial resection, maxillectomy, pedicled flap inset and pharyngeal reconstruction.

PGY5: Role as teaching assistant on above procedures, lateral skull base procedures, microvascular flap inset.

Diagnostic Oriented Learning

Outpatient skills are honed and perfected primarily in the outpatient staff head and neck clinic at Jackson Memorial Hospital, with additional exposure in attending clinics at the Sylvester Comprehensive Cancer Center. Greater sophistication of knowledge and understanding of the head and neck core curriculum is developed as

clinical experience increases. Clinical decision making is taught and critiqued in the weekly multidisciplinary head and neck tumor conference. Operative experience gains a greater breadth and depth progressively through the residency training, while medical management of head and neck problems in the inpatient and outpatient setting is handled with increasing independence and responsibility as PGY level increases. Research opportunities are provided throughout the remaining years and are encouraged based upon interest level. Level specific learning is outlined as follows:

PGY-1: The first year otolaryngology resident gains a brief but in-depth exposure to the outpatient evaluation and management of head and neck patients in the indigent head and neck clinic. There the techniques of a proper head and neck examination, fiberoptic examination, fine needle biopsy, and head and neck imaging interpretation are emphasized. The goal of the PGY 1 resident is to gain an early familiarity with diagnostic techniques, and to gain competency in formulating an initial diagnosis.

PGY-2: The second year otolaryngology resident is expected to master the fundamentals of medical management of head and neck oncologic patients and those patients undergoing surgery for benign tumors of the head and neck. This includes the mastery of the head and neck physical examination with the appropriate use of laryngeal mirror for indirect laryngoscopy as well as the fiberoptic laryngoscope. Familiarity with basic CT scan and MRI scan findings for benign and malignant tumors of the head and neck is expected. The first year resident will develop a systematic approach to the head and neck patient as an outpatient to include appropriate history taking, accurate physical examination, familiarity with appropriate diagnostic testing and the interpretation thereof, whereby he or she may formulate a reasonable list of differential diagnoses and may distinguish among these to arrive at the proper diagnosis for each patient. These skills will be developed in the Jackson Memorial Hospital Head and Neck Clinic which meets weekly and which is staffed by a faculty member with fellowship training in head and neck oncology, as well as a chief resident and physician assistant. This approach provides a balance between hands-on teaching and considerable autonomy in the work-up and disposition of these patients as experience is gained. These skills will be further perfected as the junior resident is given the opportunity to rotate among a number of faculty members’ private clinics on the Head and Neck Service such that differences in management styles may be appreciated. Practical techniques for interacting appropriately with cancer patients in the outpatient setting are introduced. While the focus in the first year with regard to outpatient management of head and neck cancer patients will be on the appropriate development of differential diagnoses such that the proper diagnosis may be accurately identified, the medical decision making involved in the clinical management of these patients is introduced and explored at a very practical level with each patient evaluated. This comes in the form of direct supervision in the outpatient clinical setting, as well as the academic conferences such as Head and Neck Tumor Board. The second year resident is expected to have a fundamental understanding of the principals of radiation oncology and medical oncology, and the important applications of these fields in the

multidisciplinary management of the head and neck cancer patients. Mastery of the TNM staging system of head and neck cancers is mandatory, and working knowledge of treatment options and outcomes is expected for squamous cell carcinoma of the head and neck at all subsites. Emphasis for the second year resident in the Core Curriculum during this year is on mastery of the anatomy of the head and neck pertinent both to the office examination as well as surgical anatomy of the head and neck, combined with a thorough understanding of the neoplasms that affect each sub-site of the head and neck. Principals of tumor cell biology and the genetics of head and neck cancer are introduced.

As the second year resident masters the outpatient work-up and evaluation of head and neck tumor patients, the inpatient medical management of pre and postoperative head and neck surgical patients is introduced. The second year resident quickly learns the fundamentals of tracheotomy tube management, parenteral feeding tube management, as well as surgical drain management. Appropriate preoperative testing is emphasized, and a fundamental understanding of surgical procedures is mandatory as preoperative teaching and surgical consents are obtained. Postoperative wound care management is emphasized, with specific attention to assessment for postoperative fistula, postoperative bleeding complications, and the complex airway issues common to many head and neck surgical patients. Head and neck surgical emergencies are emphasized from a didactic standpoint to prepare the second year resident for clinical situations where he or she may be the first responder and primary caregiver in emergency situations. Critical care techniques are mastered in conjunction with the appropriate intensive care unit multidisciplinary teams. Throughout the head and neck rotation as second year otolaryngology resident an emphasis on appropriate patient and staff interaction is maintained. The head and neck rotation provides perhaps the a multitude of examples of effective systems based practice with regard to the coordination of the complex multidisciplinary care of head and neck cancer patients, the proper support of these patients by social services and home health agencies, and the appropriate scheduling of surgical procedures in the context of significant medical comorbidities. The complex psychosocial aspects of the care of head and neck cancer patients and their families demand a high degree of professionalism and interpersonal communication skills. These competencies are fostered, improved, and evaluated throughout the second year of otolaryngology training but with particular emphasis on the head and neck service.

Surgical expectations during the second year of otolaryngology training on the head and neck service begin with an emphasis on mastery of appropriate basic surgical skills including efficient and reliable suture tying, appropriate use of both blunt and sharp dissection techniques, and a thorough understanding of surgical anatomy. A priority is placed on mastery of the often-unheralded techniques of surgical assistant on complex head and neck procedures such as neck dissections, primary tumor resections, and a variety of reconstructive techniques. The first year resident is expected to master basic techniques of rigid upper endoscopy, straightforward head and neck procedures such as tracheotomy, submandibular gland excision, and

cervical lymph node biopsy, and is expected to participate as surgeon in more complex head and neck procedures such as neck dissection or pectoralis flap reconstruction as experience is gained. A working familiarity with the common surgical instruments and the endoscopic instrumentation in the head and neck armamentarium is expected.

Academically the second year resident on the head and neck service is expected to focus his or her reading in the general otolaryngology texts, and expand this didactic knowledge by pursuing problem focused reading in head and neck oncology texts. Landmark reference articles are highlighted for particular clinical problems as a means by which the resident may begin to build his or her personal reference library. This is facilitated by a weekly Head and Neck Journal Club held in conjunction with Head and Neck Tumor Conference where both current clinical articles as well as classic articles are discussed. Depending upon the second year resident’s interest; clinical projects such as case reports, case reviews, as well as basic science projects are encouraged as faculty-resident collaborations. Faculty assessment of the second year resident’s clinical competencies on the head and neck services is performed at a variety of levels. Direct contact in the outpatient setting is focused in the staff head and neck clinic at Jackson Memorial Hospital, but broadly encouraged among other faculty clinics. The Head and Neck Tumor Conference provides a forum for lively discussion, questioning, and debate on a weekly basis. Assessment of clinical competency at the first year level is focused on the appropriateness of differential diagnoses and the accuracy of the final diagnosis. Fundamental understanding of radiographic findings is similarly explored both in the outpatient clinical setting as well as in the Head and Neck Tumor Conference. Medical management skills of pre and postoperative inpatients are evaluated both with the assistance of the senior resident as well as by direct attending rounds with the house-staff on an individual basis. Surgical competencies are assessed by direct faculty interaction with the junior resident as primary surgeon and first assistant, or as assistant to the junior resident as primary surgeon were appropriate.

By the end of the second year resident’s experience on the head and neck service, he or she will be prepared to provide a thorough and appropriate evaluation of the head and neck patient in order to arrive at an accurate diagnosis, to understand the treatment options that the patient will have and begin to formulate treatment plans among those options, to develop the fundamental surgical skills of open head and neck surgical procedures, of diagnostic endoscopic techniques, both as assistant, as well as surgeon for a common head and neck surgical cases, and finally to master the techniques of postoperative care as outlined above.

PGY-3: The third year otolaryngology resident continues to function as the junior resident on the head and neck service. The daily responsibilities of this resident are as during the first year, with clinic time spent primarily in the staff clinic at Jackson Memorial Hospital with ample opportunity for supervision and guidance from both a senior resident and faculty member. Understanding of complex head and neck treatment paradigms is expected to be mastered, and greater sophistication in physician-patient interaction, particularly with regard to communication of treatment

options with patients, is expected. Weekly participation in Head and Neck Tumor Conference provides opportunities for resident teaching as well as faculty evaluation of each resident’s progress in these areas. Operative experience during the third year emphasizes greater participation as surgeon in more complex surgical procedures to include neck dissection, parotidectomy, thyroidectomy, and primary tumor resections including total laryngectomy and composite resections. Broad experience in the full range of head and neck surgical procedures is continued as first assistant where appropriate. Encouragement of head and neck related research interests are actively encouraged among a broad range of research projects in the head and neck division.

PGY-4: The fourth year otolaryngology resident transitions to the senior resident role on the Head and Neck Service, and his or her responsibilities increase accordingly. Outpatient management and medical decision making in the staff clinic becomes the primary responsibility of the senior resident. Readily available attending input provides for a smooth transition between the junior and senior resident roles in this context. A more global responsibility is assumed for the care of the head and neck patients in the staff clinic. The senior resident is integral in the decision making process, the communication of information to patients such that truly informed decisions are made, and finally the shepherding of patients through their treatment. Staff patients are generally presented by the senior resident at the Head and Neck Tumor Conference, providing additional opportunities for comments and critiques of management plans based upon resident evaluation of all available data including imaging studies. Surgical work-ups of the staff patients are the primary responsibility of the senior resident in consultation with the covering attending.

Surgical experience changes significantly during this year as the third year resident will have the autonomy to assign cases between him or herself and the junior resident on the service. The senior resident is expected to review the running totals of all their head and neck cases as surgeon and assistant with the attending on the service responsible for resident evaluations. This interaction will assist the resident in their selection of cases to assure an adequate numbers of cases are performed in the proper distribution. Much greater emphasis is placed in this year on primary tumor resection to include more advanced techniques such as conservation laryngectomy, endoscopic laser resections of primary tumors, and more sophisticated reconstructions. Participation in both anterior and lateral skull base procedures as surgeon is expected. Pedicled flap harvest and inset is emphasized, and familiarity with various microvascular options for reconstruction with appropriate indications is stressed. Finally the senior resident assumes a teaching role as teaching assistant for his or her junior resident for cases such as tracheotomy, submandibular gland excision, etc. Both primary surgeon and teaching assistant experience is broadly gained with the patient populations of both Jackson Memorial Hospital and the University of Miami Hospital and Clinics/Sylvester Comprehensive Cancer Center.

The senior resident on the Head and Neck service assumes an administrative role beyond that required for individual patient care issues and questions. Resident and fellow case assignment and attending resident-coverage are determined by the senior resident. These assignments require organization and planning, and become a useful measure of each senior resident’s ability to manage the service efficiently and effectively.

For those residents considering head and neck subspecialty fellowship training additional time is spent in faculty counseling. Research opportunities are encouraged and fellowship application strategies are reviewed.

PGY-5: The chief resident year provides the opportunity to bring together all that has been learned in the management of head and neck patients in the preceding years. The chief resident is experienced in the medical and surgical management of these patients, has developed proper methods of physician-patient and physician-staff interaction, and is familiar with the administrative responsibilities of the service. A critical assessment of case numbers as well as perceived areas of weakness is made in conjunction with the attending responsible for resident evaluation on the service. Care is taken to be sure that these areas are addressed in terms of surgical case assignments. The entire range of head and neck surgical procedures are included. Opportunities for traditionally “fellow-level” cases are crafted depending upon individual chief resident interests, including advanced skull base procedures as all as microvascular reconstruction. Resident teaching is also emphasized, both in the operating room as well is in didactic and conference settings. Research projects are concluded. Perhaps most importantly the opportunity for individual faculty interaction is strongly encouraged as management styles and operative techniques are fine-tuned and career plans are finalized.

Continuity of Care: A resident continuity clinic with emphasis on head and neck patients has been developed. As the residents rotate through the head and neck service, all new patients seen and evaluated by them during their time on the head and neck service will become enrolled in their individual continuity clinic. This patient cohort has been identified as most likely to remain in our clinics over a period of 4 years. Most others are treated and returned to their primary providers.

Residents see their continuity patients once every six weeks, seeing these patients concurrent with the weekly head and neck clinic as run by the head and neck service. This provides for attending coverage of both the weekly head and neck resident clinics as well as the resident continuity clinic, as two residents are scheduled each week for their continuity clinic in the morning or afternoon of the head and neck clinic days. The resident head and neck continuity clinic will be staffed by the attending head and neck surgeon available in the resident head and neck clinic. Any clinical issues identified in continuity clinic follow-up that mandate intervention or evaluation earlier than a six week evaluation schedule will be transferred to the supervision of the residents on the head and neck

service at that time. Otherwise, all other regular head and neck related follow-up for these patients will be maintained within each individual resident’s continuity clinic. The continuity clinics were initiated in December of 2003, although implementation of the clinics has been a logistical challenge with progress still to be made.

MEDICAL KNOWLEDGE

Residents on the head and neck rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to Otolaryngology (ie, auditory, olfactory, salivation, airway physiology), but also as it applies to pertinent disease processes, including benign and malignant neoplastic processes, that are encountered on the head and neck rotation. Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these basic principles with 2 weeks spent on the head and neck service. During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core curriculum and basic science lectures given throughout the year, while rotation specific conferences including the weekly multidisciplinary tumor conference and the monthly thyroid conference and head and neck journal club provide opportunities for didactic and interactive teaching while on the rotation. The head and neck core curriculum lecture topics for the 2008-2009 academic year are summarized below. Residents rotating on the head and neck service are expected to develop an increasingly sophisticated understanding of these topics in their application to real clinical scenarios and patient problems. This occurs in a graduated fashion by post-graduate year, such that the PGY2 and 3 residents have an understanding of the fundamental concepts of tumor biology, clinical cancer staging, and options for therapy. The senior residents are expected to develop a greater depth of understanding of these topics while demonstrating the ability to correctly apply these topics to specific and challenging clinical scenarios. Residents at all levels of training are expected to demonstrate the appropriate application of medical knowledge and relevant medical literature to each particular clinical problem.

Didactic Curriculum: The head and neck didactic curriculum is based on the head and neck core curriculum lecture series. Lecture topics for the 2008-2009 academic year include thyroid/parathyroid disorders, sinonasal malignancies, oral cavity/oropharynx malignancies, larynx/hypopharynx malignancies, neck dissection/N0 neck management, head and neck reconstruction, salivary gland

neoplasms, and tumor biology with applied basic science principles of chemotherapy and radiation oncology. These lectures are given by faculty from the Departments of Otolaryngology, Pathology, Radiation Oncology, and Medical Oncology. One grand rounds lecture per month is dedicated to a head and neck topic. The weekly head and neck multidisciplinary head and neck tumor board is a treatment planning conference but also functions as a resident and fellow teaching conference, with participation of faculty, residents and fellows from otolaryngology, radiation oncology, medical oncology, pathology, and radiology. A monthly thyroid conference functions in a similar manner as the head and neck tumor board, with participation from representatives from otolaryngology, general surgery, endocrinology, radiation oncology, nuclear medicine, radiology, and pathology. The head and neck journal club occurs at least once monthly following the Thursday afternoon head and neck tumor conference.

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents on the head and neck service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the head and neck rotation in the context of the multidisciplinary tumor conference and head and neck journal clubs. Residents’ present head and neck patients cared for during their head and neck rotation at the quarterly morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident on the head and neck rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS

The head and neck resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. The importance of interpersonal and communication skills is stressed at every level of training

throughout the head and neck rotation. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings where difficult and challenging topics such as end of life decisions are encountered, formal conference presentations, as well as in clear and precise medical writing techniques. The head and neck resident is expected to communicate effectively with staff and ancillary personnel as one who is part of a complex multidisciplinary treatment team caring for the cancer patient. Evaluation of these skills comes from all levels, including feedback from clinic nursing and operating room personnel in the form of 360 degree evaluations.

PROFESSIONALISM

The head and neck service residents are expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are responsible for demonstrating ethical and professional behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The head and neck residents are expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate and awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the head and neck rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. Important billing and coding issues are introduced during the first years of training since all operative cases are coded with appropriate diagnosis codes through computers in the operating room at the conclusion of each procedure. These processes are particularly important on the head and neck service where complex patient needs often collide with the reality of limited patient resources. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents

facilitate home health needs, inpatient rehabilitation, coordination of follow-up care, and negotiate these services in the context of the family social issues, insurance limitations, and the service availability. The resident works closely with patient families and other related professionals, including social workers and representatives of home health agencies, to accomplish these complex tasks. Mastery of this practical understanding of systems based practice principles as they apply to the individual patient begins in the first clinical years on the head and neck service, and progresses to a greater sophistication in the senior years of training.

Useful Treatment Protocols:

DVT Prophylaxis: Start on POD1 in all patients unless contraindicated.

Jackson/SCC/BPEI/VAFragmin 5000 units SQ daily

Or

Heparin 5000 units SQ Q 8 Hours

UMH:Lovenox 40 mg SQ BID

OrHeparin 5000 units SQ Q 8 Hours Serial compression devices on at all times when patients are non-ambulatory; OOB/ambulate early, PT/OT as needed Post-operative prevention of hypocalcemia in patients undergoing total thyroidectomy: Decision to initiate prophylactic calcium supplementation based on attending preferance and intra-operative details. 1.) Prophylactic calcium supplementation: 2 gram cal citrate tid, 0.25 microgram calcitriol qd. Ionized calcium q6-8hrs x 3. If values are stable and last iCa++ is greater than 1.05, then home on same regimen. Otherwise, titrate PO calcium supplementation accordingly. Endocrinology consultation in cases of refractory hypocalcemia/cases where patients require titration of IV Ca++ drip.

2.) Post-operative monitoring for hypocalcemia in post-thyroidectomy patients who do not receive prophylactic supplementation: iCa++ q6hrs in first 24hr period, q6-8hrs subsequently

* if iCa++ is < 0.90 or patient has signs of symptoms of hypocalcemia with an iCa++ < 1.0: replace Ca++ with 2gm IV Calcium gluconate, slow IVPB and inititiate calcium supplementation as above.

* if iCa++ values are stable and last iCa++ is above 1.05, then patient can be discharged home without Ca++

EDUCATIONAL GOALS & OBJECTIVES: OTOLOGY

Residents each year will complete a two month rotation in otology and neurotology in each of the PGY 2-5 years. Although all the Residents will be exposed to and are expected to participate in all aspects of otology & neurotology, certain milestones should be adequately achieved at the end of each year of residency training. The level specific clinical and surgical procedures to be learned are listed below:PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the otology rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning

Competency in these areas will be taught at a level specific manner at the beginning of each rotation. Residents will observe faculty performing these procedures. Residents will then perform weekly dissections in the temporal bone microsurgery-training center using cadaver specimens and the faculty will review these. During the second month of the otology rotation, the residents will perform the level specific clinical and surgical procedures on live patients under direct supervision of faculty members. It is expected at the conclusion of their otology rotation the residents will be able to provide a step by step description of specific procedures for which they are responsible. At the end of the rotation the otology faculty will review the residents’ competence in performing level-specific procedures and note any deficiencies. Areas of weakness will be remediated through individual counseling, additional resident observation of faculty, and  further supervised dissection of

cadavers specimens in the temporal bone microsurgery training center as needed. The number of level specific procedures performed by each resident will be counted at the end of their rotation and compared to the total number of that procedure which is expected to be performed for adequate competency based on national averages from otolaryngology training programs.

PGY-1: Otologic binolcular examination, cerumen removal

PGY-2: Foreign body, cerumen removal, myringotomy and tubes, auricular incisions, harvesting temporalis fascia graft.

PGY-3: Tympanomeatal flap, middle ear exploration, complete mastoidectomy, tympanoplasty type I.

PGY-4: Fistula repair, complete mastoidectomy, radical mastoidectomy, and excision mastoid cholesteatoma.

PGY-5: Facial recess approach mastoidectomy, ossicular reconstruction, stapedectomy, removal of middle ear cholesteatoma, labyrinthectomy, temporal bone resection, facial nerve decompression, skull base approaches.

Diagnostic Oriented Learning

Residents will be expected to acquire level specific competency in diagnosis of otologic and temporal bone disorders. The level specific diagnostic categories are listed below:

PGY-1:  The resident will be expected to become proficient at performing an otologic history and otoscopic examination with the hand-held otoscope and microscope. The important aspects of common otologic symptoms will be taught at this stage of resident training. Ability to identify normal structures on the auricle, external ear canal and tympanic membrane will be expected.  Differentiation between the normal and pathologic states of the ear will be emphasized during patient office examinations.  The resident should be able to perform a simple cleaning of and cerumen removal from the external ear canal by the completion of this year’s rotation.  Understanding of the normal function of the peripheral auditory structures and hearing will be expected.  The resident will learn the interpretation of the basic audiogram (e.g., pure-tone thresholds, speech discrimination, tympanogram, acoustic reflexes).

PGY-2: Identification of the normal landmarks of the auricle, ear canal and tympanic membrane; tuning fork examination (Weber, Rinne, Schwabach); proper use of the handheld otoscope and otologic microscope; basics of the otologic history; recognition and initial evaluation of otologic emergencies (sudden sensory hearing loss, coalescent mastoiditis, central nervous system complications of otomastoiditis, acute facial paralysis, temporal bone trauma); interpretation of basic behavioral

audiogram, tympanogram and acoustic reflex; identification of a core group of basic and common otologic disorders (acute otitis media, chronic otitis media with perforation, middle ear vascular masses, cholesteatoma, otosclerosis, Meniere’s Disease, benign paroxysmal positional vertigo, acoustic neuroma, auricular perichondritis, otitis externa, Bell’s Palsy); anesthetic blocks of the ear and ear canal.

PGY-3: Differential diagnosis of progressive or fluctuating sensorineural hearing loss, indication for cochlear implantation, interpretation of auditory brainstem response and electrocochleography, anatomy of the temporal bone by CT scanning, management of acute and chronic facial nerve paralysis, management of acute peripheral vestibular dysfunction, management of necrotizing otitis externa.

PGY-4: Interpretation of vestibular testing (electronystagmography, rotary chair, posturography); positional nystagmus tests ( Dix-Hallpike)  and particle re-positioning maneuvers (EPLEY); temporal bone  and posterior cranial fossa anatomy by magnetic resonance imaging; evaluation and management of autoimmune inner ear disease; interpretation of otoacoustic emissions testing; evaluation and management of inner ear ototoxicity; management of complications (cerebral spinal fluid, intracranial hemorrhage, acute vestibular  loss, cranial nerve paralysis, meningitis); cochlear implant candidacy.   

PGY-5: At this level the resident should be competent enough in the initial evaluation of patients using history and physical examination along with additional diagnostic test results to obtain a diagnosis that correlates to that of the faculty for all but the most complicated patients; residents at this level should be able to interpret all of the audiological and vestibular tests and their indications; the appropriate use of imaging studies (including CT scans, MRI scans, angiography, nuclear medicine tests); pre and post-operative care; multidisciplinary planning; patient family counseling; congenital and genetic disorders of the ear and hearing and temporal bone.

Residents will be evaluated on their competency of clinical diagnosis and management. Supervising faculty will review all initial intakes of new and established patients in the otology clinic. In addition Faculty will directly observe and evaluate selected resident/patient interactions in the clinic.

MEDICAL KNOWLEDGE

Residents on the otology rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to otology (ie, normal

auditory and vestibular function), but also as it applies to pertinent disease processes affecting these systems. Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these basic principles with time spent on the otology service and with audiology. During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core curriculum and basic science lectures given throughout the year, while rotation specific conferences including the weekly otology journal club provide opportunities for didactic and interactive teaching while on the rotation. The otology core curriculum lecture topics for the 2008-2009 academic year are summarized below. Residents rotating on otology service are expected to develop an increasingly sophisticated understanding of these topics in their application to real clinical scenarios and patient problems. This occurs in a graduated fashion by post-graduate year, such that the PGY2 and 3 residents have an understanding of the fundamental concepts of acute and chronic ear disease, disorders of vestibular function, otologic neoplasms, and options for therapy. The senior residents are expected to develop a greater depth of understanding of these topics while demonstrating the ability to correctly apply these topics to specific and challenging clinical scenarios. Residents at all levels of training are expected to demonstrate the appropriate application of medical knowledge and relevant medical literature to each particular clinical problem.

The didactic educational program for otology will include the following: ten core curriculum lectures, JMH otology clinical quality assurance, temporal bone laboratory dissection, formal and informal review of the literature, Grand Rounds presentation (monthly otology topic), annual Resident temporal bone course, and weekly otology journal club. Informal daily oral quizzing will take place to ensure that Residents are properly prepared for the patients that they will see, assist on and operate as primary surgeon. The sequential progress and improvement in their scores on the inservice examination otology section will serve as a guide to the progress of the residents’ fund of knowledge. It should be noted that the didactic teaching in otology, including the ten week core curriculum lecture series, is designed to incorporate all of the critical areas encompassed in the scope of knowledge report by the American Board of Otolaryngology specific to the knowledge areas in otology and neurotology.

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents on the otology service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well

beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the otology rotation in the context of the weekly otology journal club. Residents present otology patients cared for during their otology rotation at the quarterly morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident on the otology rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS

The otology resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. The importance of interpersonal and communication skills is stressed at every level of training throughout the rotation. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings, formal conference presentations, as well as in clear and precise medical writing techniques. Residents will be encouraged to engage in presentations at local and national meetings as well as manuscripts preparation of case reports, clinical and basic research studies. This type of academic activity is invaluable for resident education, and faculty of the otology section make every effort to ensure that during each residents training at least one manuscript involving otology related research is submitted to a peer reviewed journal. The otology resident is expected to communicate effectively with staff and ancillary personnel as one who is part of a complex multidisciplinary treatment team caring for the cancer patient. Evaluation of these skills comes from all levels, including feedback from clinic nursing and operating room personnel in the form of 360 degree evaluations.

PROFESSIONALISM

The otology service residents are expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social

backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are responsible for demonstrating ethical and professional behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The otology residents are expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate and awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the otology rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. Important billing and coding issues are introduced during the first years of training since all operative cases are coded with appropriate diagnosis codes through computers in the operating room at the conclusion of each procedure. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents facilitate home health needs, outpatient rehabilitation services, and coordination of follow-up care, and negotiate these services in the context of the family social issues, insurance limitations, and the service availability. The resident works closely with patient families and other related professionals, including social workers and representatives of home health agencies, to accomplish these complex tasks. Mastery of this practical understanding of systems based practice principles as they apply to the individual patient begins in the first clinical years on each clinical rotation, and progresses to a greater sophistication in the senior years of training.

EDUCATIONAL GOALS & OBJECTIVES: FACIAL PLASTIC SURGERY

Residents spend two months each year on the facial plastic and reconstructive surgery service during PGY-4 and PGY-5. Residents are also exposed to this subspecialty during all years of residency, while rotating at the Veteran’s Administration Hospital, taking trauma call, and during combined procedures that involve other subspecialties and facial plastic faculty.

The Facial Plastic service has responsibility for facial plastic patients at Jackson Memorial Hospital (JMH), the University of Miami Hospital/Sylvester Comprehensive

Cancer Center (UMHC/Sylvester), the University of Miami Hospital (UMH), the Miami Veteran’s Administration Hospital, and Anne Bates Leach Eye Hospital (ABLEH), providing opportunities for comprehensive inpatient and outpatient management of patients with facial plastic and reconstructive needs. Continuity of care is insured by resident participation in both clinical and surgical management of patients in each of these practice locations while on service. While all residents participate in the care of facial plastic patients during each year of residency, the following clinical and procedural competencies are expected to be achieved as indicated below.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the facial plastics rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning

PGY-1: soft tissue closure, tissue handling and dissection, suture selection.

PGY-2: simple cyst excision, skin grafting, open wound management after MOHS surgery or trauma, Mohs reconstruction (mainly skin grafts and local flaps), trauma airway management.

PGY-3: facial plating techniques, nasal airway surgery (mainly septoplasty, turbinate reduction), refinement of above.

PGY-4: rhinoplasty (incision, approaches, exposure, external septoplasty, closure), advanced nasal airway surgery (nasal valve reconstruction, including placement of spreader, alar batten, columelar strut, butterfly grafts); exposure and repair of facial fractures (mandibular, orbital, maxillary, frontal, nasal); advanced Mohs reconstruction (regional flap design and transfer, repair of defects involving multiple facial subunits( ie, lip and periocular reconstruction); scar revision and keloid management; facial reanimation (static sling, ectropion repair, browplasty); management of pediatric facial lesions and deformities.

PGY-5: advanced rhinoplasty (osteotomies, refinement of nasal tip, reduction and augmentation techniques); advanced repair of facial fractures (minimally invasive techniques); complex Mohs reconstruction (repair of full thickness nasal and auricular defects, calvarial bone and rib grafting, mucosal flaps); facial reanimation (dynamic slings); aging face management, including minimally invasive techniques (fillers, chemodenervation, resurfacing) and blepharoplasty; understanding of rhytidectomy, browlift, neck lift (mostly observational); microtia repair.

Competency in these areas will be taught in a level specific manner during each rotation. Residents will be exposed to many facets of reconstructive and cosmetic facial plastic surgery via participation in peri-operative patient care. Residents will learn both by assisting faculty during facial plastic procedures and by performing many of these same procedures (with faculty supervision) in a level appropriate manner. At the conclusion of the rotation, residents should be able to provide a step-by-step description of each procedure for which they are responsible. Facial plastics faculty review with residents their level of competence and note any deficiencies. Areas of weakness will be remediated through individual counseling, additional operative experience, and/or supervised dissection of cadaver specimens. At end of the rotation, the number of level specific procedures performed by each resident will be evaluated and compared to the corresponding national average for otolaryngology training programs.

Diagnostic Oriented Learning

Residents will be expected to acquire competency in the evaluation of facial plastic and reconstructive surgery patients. The level-specific diagnostic competencies are listed below:

PGY-1: evaluation and clinical management of facial trauma, including facial fractures and open wounds.

PGY-2: advanced evaluation and clinical management of facial fractures and open wounds, basic aesthetic analysis of the nose and face.

PGY-3: comprehensive aesthetic analysis of the face and nose, nasal airway evaluation (including assessment of the nasal valve and complicated septal deformities).

PGY-4: interpretation of trauma imaging studies (including CT scans, MRI scans, angiography); peri-operative management of the trauma patient, including facilitation of multidisciplinary planning and patient family counseling; evaluation and clinical management of facial scarring and keloids; assessment of patients with facial paralysis, including medical management related symptoms (especially periocular complaints).

PGY-5: advanced trauma assessment and clinical management; evaluation of complicated Mohs defects, advanced evaluation and counseling of patients seeking rhinoplasty or facial rejuvenation procedures; evaluation and clinical management of pediatric patients, including microtia.

Competency in these areas will be taught at a level specific manner during each rotation. Residents will be exposed to exposed to the evaluation of facial plastic patients by faculty, and actively participate in the assessment of patients with faculty supervision. Supervising faculty will review initial intakes of new and established patients in the facial plastic clinic and/or emergency room. In addition, faculty will directly observe and evaluate selected resident/patient interactions in the clinic. Facial plastics faculty review with residents their level of competence and note any deficiencies. Areas of weakness will be remediated through individual counseling, and/or additional clinic experience.

Residents also spend one month each year on the oral and maxillofacial surgery service during PGY4 and PGY5. During this rotation, residents are exposed to the evaluation and management of patients with facial trauma. Residents participate in clinical assessment and procedural care in the emergency room and clinic. In addition, residents serve as primary surgeon during facial plating procedures for a variety of facial fractures. Specific objectives are listed below:

1. Proficiency in performing an appropriate oral and maxillofacial examination, including definitive understanding of occlusal relationships and other cephalometric relationships.

2. Competence in the evaluation of facial trauma patients with primary and advanced, complicated and/or multiple injuries to the facial skeleton (in the clinical and emergency care settings).

3. Competence in the discussion of treatment alternatives and formulation of a management plan for the facial trauma patient.

4. Competence in the pre-operative preparation of the patient for facial trauma procedures (i.e., placement of maxillomandibular fixation wires prior to surgical procedures).

5. Gain experience with various plating systems and the principles of immediate reconstruction of the facial trauma.

6. Gain experience as resident surgeon in the care of patients with mandibular, zygomaticomaxillary complex, orbital floor, LeFort, and other facial fractures.

7. Competence in recognition of surgical complications related to facial trauma procedures, and an understanding of their treatments.

MEDICAL KNOWLEDGE

Residents on the facial plastics rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the

application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to facial plastic surgery, but also as it applies to pertinent disease processes affecting these systems. Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these basic principles with time spent on the facial plastics rotation, as well as time spent on the general plastics and burn rotations. During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core curriculum and basic science lectures given throughout the year. Didactic sessions in facial plastic surgery include core curriculum lectures (eight to ten per year), grand rounds presentations (monthly topic), facial plastic conferences (quarterly), formal and informal literature review, and departmental sponsored CME courses. In addition, separate annual hands-on cadaveric dissection courses are provided in the following areas: (1) rhinopplasty and (2) facial rejuvenation and soft tissue surgery. Simulation laboratory training in facial trauma management, including technical skills related to plating of mandibular, maxillary, orbital, frontal fractures, is provided annually. It should be noted that the didactic teaching in facial plastics is designed to incorporate all of the critical areas encompassed in the Scope of Knowledge report by the American Board of Otolaryngology, and to the meet educational goals established by the AAO HNS Resident Online Study Guide Curriculum.

Residents at all levels of training are expected to demonstrate the appropriate application of medical knowledge and relevant medical literature to each particular clinical problem. Residents will be orally quizzed during clinic and surgical procedures to assess knowledge and ensure clinical competency. The sequential progress and improvement in their scores on the inservice examination will serve as a guide to the progress of the residents’ fund of knowledge in facial plastic and reconstructive surgery.

PRACTICE-BASED LEARNING AND IMPROVEMENT

Residents on the facial plastics service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the facial plastics in the context of journal clubs and patient-specific didactic teaching and dialogue with the facial plastics faculty. Residents present facial plastic surgery or trauma patients cared for during their

rotation at the quarterly morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident on the rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS

The facial plastics resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. The importance of interpersonal and communication skills is stressed at every level of training throughout the rotation. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings, formal conference presentations, as well as in clear and precise medical writing techniques. Evaluation of these skills comes from all levels, including feedback from clinic nursing and operating room personnel in the form of 360 degree evaluations. Residents will be encouraged to engage in presentations at local and national meetings as well as manuscript preparation of case reports, clinical and basic research studies. Furthermore, active participation in academic facial plastic and reconstructive surgery is encouraged as a step towards fellowship training in this subspecialty, if further training is desired.

PROFESSIONALISM

The facial plastics service resident is expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are responsible for demonstrating ethical and professional

behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The facial plastics resident is expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate and awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the facial plastics rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. Important billing and coding issues are introduced during the first years of training since all operative cases are coded with appropriate diagnosis codes through computers in the operating room at the conclusion of each procedure. Education into the distinction between cosmetic (self-pay) procedures vs. functional procedures that will be covered by insurance occurs with direct input from the faculty and their management of private cases. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents facilitate home health needs, outpatient rehabilitation services, and coordination of follow-up care, and negotiate these services in the context of the family social issues, insurance limitations, and the service availability. The resident works closely with patient families and other related professionals, including social workers and representatives of home health agencies, to accomplish these complex tasks. These issues are commonplace for the trauma patients cared for by the service. Mastery of this practical understanding of systems based practice principles as they apply to the individual patient begins in the first clinical years on each clinical rotation, and progresses to a greater sophistication in the senior years of training.

EDUCATIONAL GOALS & OBJECTIVES: PEDIATRIC OTOLARYNGOLOGY

Residents will have varying levels of formalized pediatric training throughout the five-year training process. During the PGY-1 year, interns spend one to two weeks rotating through pediatric otolaryngology, participating in the attending physician clinics, JMH clinic, and in the operating room observing procedures with the pediatric otolaryngology team. In the PGY-2 year, residents will spend 2 days of the week during each their two-month rotations participating in pediatric otolaryngology care. One day each week is spent in the JMH pediatric otolaryngology clinic under the direct supervision of a faculty member, and one day is spent in the operating room performing basic pediatric otolaryngology procedures. During the PGY-4 and PGY-5 years, each resident will complete a two-month rotation dedicated to only pediatric otolaryngology. This includes direct participation in the private clinics of each faculty member, active participation in the operating room at least two days a week as primary resident surgeon, and one day

a week directing the JMH pediatric otolaryngology clinic. During the JMH clinic, the Peds Service Chief is responsible for teaching PGY-1 and 2 residents and medical students about the care of these patients, under the supervision of the attending physician. One day a week is spent as both primary surgeon and teaching surgeon in the operating room.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the pediatric otolaryngology rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning

Residents begin their pediatric experience in both the clinic and the operating room, mastering the head and neck examination in children and simple procedures such as fiberoptic laryngoscopy and ear examination in the uncooperative child. Surgical skills are acquired as the primary surgeon under the direct supervision of the teaching faculty member and the senior resident surgeon as teaching assistant. These initial cases, including tonsillectomy and myringotomy and tube placement, are used to teach principles of tissue dissection and microscopic ear surgery. Head and neck cases such as node, gland or mass excision are valuable teaching cases for the junior resident to learn principles of retraction, exposure and hemostasis.

After basic competency is demonstrated in these initial phases as primary surgeon and as assistant surgeon for more complicated cases, the transition is made to assume more responsibility as the primary surgeon for complex cases under direct guidance of the faculty member. At the completion of each rotation, it is expected that the resident will be able to describe the indications, potential risks, benefits, complications and alternatives to each surgery in addition to describing in step-wise fashion each procedure. At the end of each rotation, faculty reviews the resident competence in each level-specific procedure and any areas of weakness are identified. Also, an index clinical and surgical patient are presented and assessed by the faculty at the resident’s appropriate level of training. Any specific deficiencies are addressed through individual

counseling and education, additional training time observing and under the observation of each faculty member, and further clinical experience. Faculty review resident case logs to assess any deficient areas. As senior residents, in addition to acting as primary surgeon for complex cases, valuable experience is gained as a teaching assistant supervising the junior resident procedures. Certain milestones are expected to be reached at the completion of each year of pediatric otolaryngology. Specific procedures that should be mastered by the end of each year of training are as follows:

PGY-1: Initial pediatric otolaryngology history and physical exam, clinic-based procedures such as the microscopic ear exam, flexible nasopharyngoscopy in selected children, suture removal and dressing changes.

PGY-2: Complete pediatric history and physical exam, microscopic ear examination, foreign body and cerumen removal, myringotomy and tube placement, tonsillectomy and adenoidectomy.

PGY-3: Tympanoplasty, cortical mastoidectomy, basic endoscopy including flexible and direct laryngoscopy, bronchoscopy and esophagoscopy, esophageal foreign body removal, sinonasal endoscopy

PGY-4: Excision of neck masses, branchial cleft cysts and arch anomalies, basic endoscopic sinus surgery (including maxillary sinus antrostomy and anterior ethmoidectomy), endoscopic laryngeal and bronchoscopic procedures including papilloma removal and excision of tracheal lesions

PGY-5: Laryngotracheal reconstruction, excision of larger neck masses, cholesteatoma removal and middle ear reconstruction, extensive endoscopic sinus surgery including drainage of orbital and frontal sinus abscesses, complicated endoscopy and airway evaluation

Diagnostic Oriented Learning

Residents are expected to acquire level-specific competency in the diagnosis and treatment of specific disorders within pediatric otolaryngology. Level-specific diagnostics are listed as follows:

PGY-1/PGY-2: Primary objective in the first year of pediatric otolaryngology is to learn the examination of the normal child and identification of normal findings on physical exam, radiographic and audiologic studies in children. Identification of primary pathology, including complications, includes a basic understanding of the pathology, pathophysiology, and initial treatment of otitis media, tonsillitis, obstructive sleep apnea and airway obstruction. In addition, on-call responsibilities include primary management of emergent situations including assessment of airway obstruction, complications of otitis media and sinusitis, and control of hemorrhage and epistaxis.

PGY-3: In conjunction with the learning process in other subspecialties in otolaryngology, residents at this level are expected to learn the diagnosis, evaluation and treatment of common otologic conditions in children including chronic suppurative otitis media, cholesteatoma and sensorineural hearing loss; they are also expected to have a basic interpretation of normal and abnormal audiograms and auditory brainstem response testing. General otolaryngology skills include interpretation of allergy testing and allergy management in children and a preliminary understanding of voice disorders and sinusitis at age-specific levels. Residents are expected to have read and be able to identify basic airway pathology in children including flexible laryngoscopy and identification of supraglottic and glottic laryngeal pathology and endoscopic evaluation of subglottic and tracheal pathology. Head and neck skills include the diagnosis and workup of neck masses and the differentiation of neoplastic, inflammatory and congenital lesions. Encouragement of pediatric otolaryngology-related research projects in conjunction with faculty research interests are developed in this year.

PGY-4: At this level residents are expected to act as senior patient managers in the comprehensive care of the pediatric patient in conjunction with appropriate pediatric specialty services. This includes a comprehensive management of otolaryngology problems in the child with multiple medical problems. Specifically, management of tracheotomy-dependent children includes an understanding of underlying pulmonary and gastrointestinal disorders and the senior resident will coordinate care and management in conjunction with these services. The senior resident will be responsible for endoscopic examination and surgical treatment planning for complex airway disorders under the faculty supervision. In addition, senior residents are expected to study imaging and interpret sinonasal pathology on endoscopic examination and CT and MRI scanning and plan medical and surgical treatments appropriately based on the scientific literature. Senior residents should also be able to plan surgical management of head and neck masses in children based on physical exam and appropriate imaging.

PGY-5: As a chief resident in pediatric otolaryngology residents are expected to fully integrate patient management and evaluation skills to arrive at a diagnosis and treatment plan that is commensurate with faculty evaluation and based on pertinent scientific literature. At this level residents should be able to complete and entire physical exam, review appropriate audiologic and radiographic studies and formulate a management plan based on the above. This also includes comprehensive preoperative counseling, postoperative management, multidisciplinary care planning, and most importantly family and patient counseling.

Residents will be evaluated on their competency of clinical diagnosis and management. The residents will present and review with the faculty all patients necessitating possible admission or surgery in the pediatric otolaryngology clinic. In addition the faculty will directly observe and evaluate selected resident/patient interactions in the clinic. Inpatient hospital consultations will be reviewed and examined with faculty members to maximize the educational process.

MEDICAL KNOWLEDGE

Residents on the pediatric otolaryngology rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to pediatric otolaryngology as well as the pertinent disease processes affecting these systems. Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these basic principles with time spent on the pediatric otolarynoglogy service. The educational program in pediatric otolaryngology includes the following: 8 core curriculum lectures in aspects of pediatric otolaryngology, JMH Department of Otolaryngology Clinical Quality Assurance conference every quarter, endoscopic sinus anatomy laboratory dissection, formal and informal review of the literature, Grand Rounds presentations and a monthly Pediatric Otolaryngology Journal Club. Informal daily oral quizzing and review of surgical cases (prior to surgery) ensures that residents are properly prepared for the patients that they will see, assist on, and operate as primary surgeon. The sequential progress and improvement in their scores on the inservice examination pediatric otolaryngology subspecialty questions will serve as a guide to the progress of the residents’ fund of knowledge. Teaching in pediatric otolaryngology, including the core curriculum lecture series, is designed to incorporate all of the critical areas encompassed in the scope of knowledge report by the American Board of Otolaryngology specific to the knowledge areas in pediatric otolaryngology. PRACTICE-BASED LEARNING AND IMPROVEMENT Residents on the pediatric otolaryngology service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the pediatric otolaryngology rotation in the context of journal clubs and patient-specific didactic teaching and dialogue with the pediatric otolaryngology faculty. Residents present pediatric patients cared for during their rotation at the quarterly morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident

on the rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS The pediatric otolaryngology resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. The importance of interpersonal and communication skills is stressed at every level of training throughout the rotation. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings, formal conference presentations, as well as in clear and precise medical writing techniques. These skills are critically important in interactions with children who may be afraid and may have very limited understanding of their surroundings, as well as their families. Evaluation of these skills comes from all levels, including feedback from clinic nursing and operating room personnel in the form of 360 degree evaluations. Finally, residents will be encouraged to engage in presentations at local and national meetings, as well as manuscript preparation of case reports, clinical and basic research studies. This type of academic activity is invaluable for resident education. The faculty of the pediatric otolaryngology section makes every effort to ensure annual publications by the residents in a peer-reviewed journal pertaining to a relevant pediatric otolaryngology topic. Furthermore, active participation in academic pediatric otolaryngology is encouraged as a step towards fellowship training in pediatric otolaryngology if further training is desired.

PROFESSIONALISM

The pediatric otolaryngology service resident is expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are

responsible for demonstrating ethical and professional behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The pediatric otolaryngology resident is expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate and awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the pediatric otolaryngology rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. Important billing and coding issues are introduced during the first years of training since all operative cases are coded with appropriate diagnosis codes through computers in the operating room at the conclusion of each procedure. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents facilitate home health needs, outpatient rehabilitation services, and coordination of follow-up care, and negotiate these services in the context of the family social issues, insurance limitations, and the service availability. The resident works closely with patient families and other related professionals, including social workers and representatives of home health agencies, to accomplish these complex tasks. Mastery of this practical understanding of systems based practice principles as they apply to the individual patient begins in the first clinical years on each clinical rotation, and progresses to a greater sophistication in the senior years of training.

EDUCATIONAL GOALS & OBJECTIVES: GENERAL OTOLARYNGOLOGY

The General Service rotation provides exposure to all aspects of inpatient and outpatient general otolaryngology, with a specific emphasis on rhinology and allergy, airway disorders and laryngology. A minimum experience in certain surgical techniques should be adequately achieved at the end of each year of residency training. The level-specific clinical and surgical procedures to be learned are listed below:

Currently, the Division of General Otolaryngology consists of Dr. Roy Casiano and Dr. Jose Ruiz as otolaryngology faculty members with a specific interest and expertise in rhinology and allergy. In addition, Dr Paul Kleidermacher (otolaryngologic allergist)) provides clinical training in the diagnosis and management of otolaryngologic allergy, with special emphasis on allergy testing and immunotherapy technique. The group sees patients at UMHC/Sylvester Comprehensive Cancer Center (SCCC) or at the University of Miami Hospital (UMH), as part of a multidisciplinary team of respiratory specialists (pulmonologists, otolaryngologists, allergist, speech pathologists, and respiratory therapists). The center also contains a vocal disorders laboratory and a pulmonary functions laboratory. This multidisciplinary approach to respiratory disease has

improved the way that we treat patients and has led to numerous collaborative research efforts. Residents rotate through this Airway Center and adjacent operating rooms, at SCCC or UMH, during their two month rotation on the service as described below. Other full time members of the department also help supervise large clinical load of patients on the JMH general otolaryngology service (Dr Eshraghi, Dr Liu and Dr Thomas). In addition, residents experience a wide range of experience with common general otolaryngologic disorders as part of their VAH rotation (summarized elsewhere). Also, additional allergy experience occurs during their VAH rotation (Dr Nissim).

From the residents’ perspective, the Division of General Otolaryngology consists of a rhinology fellow, a senior resident (PGY 4 or 5), a otolaryngology consult resident for the medical center (PGY 3), and a junior resident (PGY 2). There is also a separate junior resident rotating through the VAH (summarized elsewhere). All of the residents rotate through the General Otolaryngology Division every two months over the four years of their residency. Over the course of their training all of the residents spend a minimum of 8 months on the service. During their rotation, the residents and fellow are responsible for the Jackson Memorial (JMH) general otolaryngology clinics and OR’s (see table below). While at JMH, the residents see patients and operate under the supervision of the general otolaryngology faculty. In order to keep up with the growing clinical demand and patient load (due to an increase in indigent population needing medical care in S. Florida) the department has also hired and trained a full time Otolaryngology ARNP to see patients alongside the residents in their JMH clinic. This has allowed us to develop additional educational programs for the resident, whereby the quality of the program has been enhanced. In addition, the rhinology fellow, who functions as a general otolaryngology attending, adds an additional layer of supervision in his/her daily interactions alongside the residents in the OR’s and Clinics.

The JMH, SCCC and UMH Clinic and OR supervision currently available for general otolaryngology/rhinology/allergy patients is summarized as follows:

Dr. Casiano - Monday OR at UMH or JMH Wednesday OR @ SCCC

Thursday rhinology clinic @ SCCC

Dr. Ruiz - Monday OR and clinic @ JMH or VAH Tuesday clinic and OR @ SCCC Wednesday OR at UMH

Thursday OR at JMH Friday clinic @ SCCC

Dr Eshraghi- Thursday OR at UMH

Dr Liu- Friday clinic at JMH Tuesday OR at JMH

While on the service, the residents’ and fellow’s schedule of daily activities goes as follows:

PGY Monday Tuesday Wednesday Thursday Friday4 or 5 AM JMH OR JMH OR SCCC OR Academics

(7-10 AM)JMH General ENT Clinic

PM JMH OR JMH OR SCCC OR JMH OR(>10 AM)

JMH General ENT Clinic

3 AM JMH General ENT clinic

JMH OR UMH Allergy Clinic: Dr. Kleidermacher

Academics (7-10 AM)

JMH General ENT Clinic

PM JMH General ENT clinic

JMH OR SCCC OR JMH OR(>10 AM)

JMH General ENT Clinic

2 AM JMH OR JMH Pediatrics ENT clinic

SCCC OR Academics (7-10 AM)

JMH Pediatrics Ambulatory OR

PM JMH OR JMH Pediatrics ENT clinic

SCCC OR SCCC Dr Casiano: rhinology/allergy clinic(>10 AM)

JMH Pediatrics Ambulatory OR

Rhinology Fellow

AM JMH OR JMH OR/Research

SCCC OR(rhinology)

Academics (7-10 AM)

JMH General ENT Clinic

PM JMH OR JMH OR/Research

SCCC OR SCCC Dr Casiano: Rhinology/allergy Clinic(> 12:30 PM)

JMH General ENT Clinic

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the general otolaryngology rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning

Competency in these areas will be taught in a level-specific manner at the beginning of each rotation. Initially, residents observe faculty performing these procedures. Residents then perform pre-assigned dissections in the endoscopic sinus surgery cadaver lab using fresh cadaver specimens. In addition, the residents participate in an annual endoscopic sinus anatomy course utilizing fresh-frozen cadaver specimens. They also participate in an annual allergy course with special emphasis on basic immunology and immunotherapy as a treatment option for allergy patients. Cadaver dissection will be complimented by level-specific clinical and surgical procedures under direct supervision of faculty members. It is expected that after the conclusion of their general otolaryngology rotation the residents will be able to explain the indications for surgery and provide a step by step description of the specific surgical procedures for which they are responsible. At the end of the rotation the faculty will review the residents’ competence in the level-specific procedures and note any deficiencies. Areas of weakness will be remediated through individual counseling, additional resident observation of faculty, and/or further dissection of cadavers specimens. The number of level-specific procedures performed by each resident will be counted at the end of their rotation and compared to the total number of that procedure which is expected to be performed for adequate competency, based on national averages from otolaryngology training programs.

PGY-1: Clinical examination of the upper airway and recognizing the diagnosis and management common voice/airway and sinonasal disorders. Basic OR set-up and principles behind common surgical procedures for patients suffering from sinonasal and voice complaints.

PGY-2: Tracheotomy and management of the emergent airway; direct laryngoscopy with or without simple biopsy; diagnostic bronchoscopy and esophagoscopy, microlaryngoscopy and excision of simple lesions (polyps and nodules); tonsillectomy and adenoidectomy; I & D of superficial and deep neck abscesses; excision of uncomplicated mucosal or skin lesions; septoplasty; endoscopic inferior and middle turbinoplasty or reduction; endoscopic middle meatal antrostomy in uncomplicated disease (primary cases with or without nasal polyps); CO2 laser use during microlaryngoscopy or hand-held applications (ablation or excision of simple mucosal lesions).

PGY-3: Uvulopalatopharyngoplasty; CO2 laser or radiofrequency ablation of the soft palate or tongue for the treatment of OSA and for inferior turbinate hypertrophy; partial endoscopic ethmoidectomy in patients with uncomplicated disease (primary cases with or without nasal polyps).

PGY-4: Microlaryngoscopy and excision of more complicated mucosal lesions involving more extensive mucosal or submucosal dissections (papillomas, early glottic carcinoma,

intrachordal cysts, laryngoceles, sacular cysts); total endoscopic ethmoidectomy and sphenoid sinusotomy in patients with uncomplicated disease (primary cases with or without nasal polyps); external approaches to the paranasal sinuses (Caldwell-Luc or sublabial degloving for the maxillary sinus, Lynch incision for the ethmoid sinus, trephination of the frontal sinus, bicoronal approach for frontal sinus obliteration or exploration).

PGY-5: Medialization laryngoplasty for unilateral vocal fold paralysis (Thyroplasty type I or injection techniques ); arytenoidectomy and/or cordotomy for bilateral vocal fold paralysis; partial or total endoscopic ethmoidectomy and sphenoid sinusotomies in patients with complicated disease (revision cases, sinus cavities with extensive mucosal disease, and/or osteoneogenesis); endoscopic frontal sinusotomies; direct laryngoscopy, bronchoscopy and esophagoscopy for removal of foreign bodies, keel or stent placement, radial incision and balloon dilation of tracheal stenosis, or ablation/excision of lesions (stenosis or neoplasms); endoscopic identification and repair of minor CSF leaks in the nose and paranasal sinuses; minor degrees of endoscopic skull base surgery; reconstructive procedures of the trachea or larynx after trauma or stenosis (laryngotracheoplasty or resection and primary anastomosis).

Diagnostic Oriented Learning

Residents will be expected to acquire level-specific competency in the diagnosis and treatment of common rhinologic, laryngologic, and other upper airway disorders. Residents will be evaluated on their competency of clinical diagnosis and management. The residents will present and review with the faculty all patients necessitating possible admission or surgery, in the general otolaryngology clinic. In addition the faculty will directly observe and evaluate selected resident/patient interactions in the clinic. The level specific diagnostic categories are listed below:

PGY-1: Understand the fundamentals of a comprehensive otolaryngologic history and examination, including fiberoptic nasal endoscopy and laryngoscopy. Develop familiarity with interpretation of normal and abnormal findings on sinus CT scans. Learn the basic evaluations steps of common otolaryngologic emergencies including epistaxis, and complications of head and neck infections.

PGY-2: Develop a systematic approach for the workup, diagnosis, and treatment of patients with common laryngeal, rhinologic or other upper airway complaints (OSA, stridor, shortness of breath, wheezing, etc.); Identification of the normal endoscopic and CT/MRI anatomy of the nose, nasopharynx, oropharynx, oral cavity, hypopharnx, larynx, and trachea; Identification of the main sinus cavities, (ethmoid, sphenoid, frontal, and maxillary) during routine postoperative debridement; Identification of abnormal lesions in the upper airway (neoplasm, polyps, infection); Understand the basic concepts and indications for objective measurements in the voice laboratory (videostrobolaryngoscopy, air flow studies, EMG, acoustical analysis). Develop an understanding for the appropriate use of perceptual measurements in the differential diagnosis of vocal disorders (voice tremors, spasmodic dysphonia, stroke and other

neurologically impaired patients, vocal fold paralysis, muscular tension dysphonia, and mass lesions on the vocal folds). Begin to learn the wide variety of growing in-office procedures and techniques available to otolaryngolists to make a diagnosis and/or for therapeutic intervention.

PGY-3: Understand the indications and technique for outpatient transnasal or transoral endoscopic tissue biopsy or culture of suspicious upper airway lesions in the clinic; Know the appropriate work-up and identification of the site of epistaxis; Know the indications and techniques to control epistaxis from traditional packing techniques to endoscopic management in the outpatient clinic; Know the differential diagnosis and different treatment plans for common laryngeal and sinonasal disorders (neoplastic, inflammatory, and/or infectious); Know how to perform basic objective and perceptual measurements and interpret normal versus abnormal findings in patients with common vocal complaints; Know the basic interpretation of sleep study results in patients with obstructive sleep apnea or snoring; Know the basic interpretation of pH probe evaluations, modified and regular swallowing studies, and monametric studies in the workup of patients suffering from dysphagia, odynophagia, or symptoms of laryngopharyngeal reflux disease; Know the appropriate work-up and treatment plan for patients with laryngopharyngeal reflux disease. PGY-4: Understand the different anatomic variants occurring in the nose and paranasal sinuses (endoscopic and CT). Know how to interpret CT and MRI scans in the presence of sinonasal, laryngeal, oral cavity, oropharynx, nasopharynx, or neck pathology (neoplastic, inflammatory, or infectious).

PGY-5: At this level the resident should be competent enough in the initial evaluation of patients using history and physical examination along with additional diagnostic test results to obtain a diagnosis that correlates to that of the faculty members for all but the most complicated patients; residents at this level should be able to interpret all of the special objective voice measures in the vocal disorders laboratory and their indications; the appropriate use of imaging and laboratory studies (including CT scans, MRI scans, angiography, nuclear medicine tests); pre and post-operative care; multidisciplinary planning; and patient/family counseling.

Otolaryngologic Allergy:

Allergy Rotation at UMH:

The Department of Otolaryngology recognizes allergy training as part of the residents’ overall core curriculum in Otolaryngology/Head and Neck Surgery. We have two programs to address this issue: 1) Rotation through an otolaryngologic allergy clinic at UMH and 2) an annual resident allergy course (both described below). The mission of allergy training in otolaryngology is to disseminate knowledge and confidence in the evaluation and treatment of inhalant and food allergies as promoted by the AAOA. The Division of General Otolaryngology is responsible for the allergy curriculum.

Allergy Rotation Objectives: The goal of this rotation is to introduce the resident to the clinical practice of allergy testing and immunotherapy. The resident will work with an experienced allergy nurse under physician supervision who will discuss and demonstrate the techniques involved with serial endpoint titration and allergy desensitization. At the conclusion of the rotation, the resident will understand the following points:  manifestations of allergic disease and indications for allergy testing and

immunotherapy theory/immunology of allergic response and immunotherapy the difference between inhalant and food allergies the difference between seasonal and perennial allergies the contraindications to immunotherapy/testing theory behind serial endpoint titration which is the preferred method of testing of the

American Academy of Otolaryngic Allergy technique of intradermal testing technique for preparing serial dilutions to be used in immunotherapy risks/adverse effects of allergy testing and immunotherapy recognizing the signs and symptoms of anaphylaxis and understanding the

measures to prevent and to treat it. recognizing common associated respiratory ailments (asthma, bronchitis, laryngitis,

etc.) and learning how to treat these comorbidities, to maximize the patients’ long-term outcomes.

understanding the principles of treatment of inhalant allergy by environmental control and pharmacotherapy.

knowing the indications, probable mechanisms, and potential side effects of pharmacotherapy.

Hands-on allergy and rhinology training begins at the PGY 2 level. The resident sees patients under faculty supervision in the JMH General ENT Clinics, and in the SCCC Rhinology/Allergy Clinic with Dr Casiano. In this clinic, the resident learns to take an appropriate rhinologic/allergy history and physical, develop a course of action, and learn various pharmacotherapeutic measures available to treat chronic inflammatory disease of the upper airways. At SCCC, the resident gets his/her initial exposure to a multidisciplinary rhinology/allergy practice. In addition, the resident gets exposure to other comorbid conditions affecting the respiratory system, ranging from vocal disorders to immunologic diseases. In addition, the PGY 2 resident receives hands-on training (to develop hand-eye coordination) with the sinus telescope, by performing postoperative sinonasal debridements, biopsies, cultures, and other office-based laryngologic and rhinologic procedures.

At the PGY 3 level, the General Otolaryngology resident spends time in the allergy clinic on Wednesdays at UMH. Under faculty supervision, this resident is responsible for obtaining the initial allergy history. He/she then reviews the history and formulates a treatment plan with the faculty. Many times this may involve pharmacotherapeutic

measures such as the use of various anti-inflammatory agents. In other patients, immunotherapy would be a reasonable option. During this rotation, the resident obtains hands-on experience with intradermal testing, interpretation of results, management of potential complications (i.e., local skin reactions, anaphylaxix, etc.), formulation of a treatment plan, and administration of desensitization shots.

In the allergy clinic, residents learn confirmatory testing demonstrating the presence of allergen-specific IgE indirectly through skin testing or directly by in-vitro testing. Skin testing includes prick and puncture (scratch testing), patch testing, and intradermal testing. The residents learn to actively evaluate for the pertinent geographical antigens, read the wheal and allergic parameters from the skin, and understand the mixing of antigens and the safe practice of immunotherapy. In select patients, in-vitro testing may be more appropriate. This includes the RAST (radioactive marker) and occasionally the ELISA (enzymatic marker) test. Allergy treatment also emphasizes environmental control and pharmacotherapy (including antihistamines, decongestants, mast cell stabilizers, systemic and topical corticosteroids, and leukotriene inhibitors). New and innovative pharmacotherapeutic measures (ie, IgE binding IgG or “Xolair”) are constantly reviewed in conferences and during clinical activities.

MEDICAL KNOWLEDGE

Residents on the general otolaryngology rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to general otolaryngology (i.e. normal sinonasal physiology), but also as it applies to pertinent disease processes affecting these systems (i.e. rhinosinusitis and allergy). Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. In addition, the Otolaryngology 2 month rotation during the PGY 1 year reinforces these basic principles with time spent on the general service rotation. During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core curriculum and basic science lectures given throughout the year.

Didactic Curriculum:

The didactic educational program for general otolaryngology will include the following: fifteen core curriculum lectures (5 in laryngology and voice, 5 in rhinology, and 5 in allergy and immunology), JMH Department of Otolaryngology Clinical Quality Assurance conference every quarter, endoscopic sinus anatomy laboratory dissection, formal and informal review of the literature, Grand Rounds presentations (monthly laryngology, allergy, or rhinology topic), and an annual resident endoscopic sinus anatomy course. Informal daily oral quizzing and review of surgical cases (prior to

surgery) will take place to ensure that residents are properly prepared for the patients that they will see, assist on, and operate as primary surgeon. The sequential progress and improvement in their scores on the in-service examination general otolaryngology sections will serve as a guide to the progress of the residents’ fund of knowledge. It should be noted that the didactic teaching in general otolaryngology, including the 15 week core curriculum lecture series, is designed to incorporate all of the critical areas encompassed in the scope of knowledge report by the American Board of Otolaryngology specific to the knowledge areas in general otolaryngology (with specific attention to the areas of upper airway disorders, laryngology, voice, rhinology, and allergy).

Allergy Core Curriculum:

Formal lectures in otolaryngologic allergy are given as part of the annual core curriculum and as part of the annual resident allergy course. The topics covered in this course are as follows: Immunology of Allergy, Contemporary Pharmacotherapy for Otolaryngologic Allergist, Principles and Methods of Skin and In Vitro Testing, Antigen Selection: Concepts, Seasons and Identification, Allergy Emergencies for the Otolaryngologist. Yearly visiting professor rounds (local or national) in otolaryngologic allergy are integrated into the curriculum. Additionally, didactic teaching of otolaryngologic allergy and immunology occurs periodically during our Grand Rounds throughout the year.

The core curriculum enables the residents and medical students to understand the pathogenesis and basic sciences of immunology including the classic Gell and Coombs reactions, and the involvement of complement, prostaglandins, leukotrienes, and cytokines (most notably interleukins). During lectures, the residents are familiarized with the potential complications of allergy treatment such as the causes of anaphylaxis, the signs and symptoms of anaphylaxis and its management (including use of tourniquet, epinephrine, airway support, circulatory support, and appropriate pharmacotherapy). In addition, food allergy is addressed in a manner consistent with the AAOA standards.

PRACTICE-BASED LEARNING AND IMPROVEMENT Residents on the general otolaryngology service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the general otolaryngology rotation in the context of journal clubs and patient-specific didactic teaching and dialogue with the general otolaryngology faculty. Residents present patients cared for during their general service rotation at the quarterly

morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident on the rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS The general otolaryngology resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. The importance of interpersonal and communication skills is stressed at every level of training throughout the rotation. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings, formal conference presentations, as well as in clear and precise medical writing techniques. Evaluation of these skills comes from all levels, including feedback from clinic nursing and operating room personnel in the form of 360 degree evaluations. Finally, residents will be encouraged to engage in presentations at local and national meetings, as well as manuscript preparation of clinical and basic research studies. This type of academic activity is invaluable for resident education. The faculty of the general otolaryngology section makes every effort to ensure annual publications by the residents in a peer-reviewed journal pertaining to a relevant general otolaryngology clinical or basic science research topic.

PROFESSIONALISM

The general otolaryngology service resident is expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are responsible for demonstrating ethical and professional behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The general otolaryngology resident is expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the general otolaryngology rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. Important billing and coding issues are introduced during the first years of training since all operative cases are coded with appropriate diagnosis codes through computers in the operating room at the conclusion of each procedure. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents facilitate home health needs, outpatient rehabilitation services, and coordination of follow-up care, and negotiate these services in the context of the family social issues, insurance limitations, and the service availability. The resident works closely with patient families and other related professionals, including social workers and representatives of home health agencies, to accomplish these complex tasks. Mastery of this practical understanding of systems based practice principles as they apply to the individual patient begins in the first clinical years on each clinical rotation, and progresses to a greater sophistication in the senior years of training. EDUCATIONAL GOALS & OBJECTIVES: MIAMI VA ROTATION

Residents rotate through the Miami VA Medical Center twice during the PGY 2 year. Each rotation is two months in length. The educational director on site for the rotation is Kenneth Nissim, MD, a member of the faculty of the Department of Otolaryngology at the University of Miami with interests in general otolaryngology and sleep medicine. Subspecialty faculty also sees patients and performs surgery in the areas of Head and Neck Oncology, Otology, and Facial Plastic and Reconstructive Surgery. This rotation provides a comprehensive, mentored exposure to the care of general, head and neck, otology, facial plastic and sleep medicine patient. This exposure includes direct involvement with the initial patient evaluation and diagnostic work-up, medical decision making, surgical planning, management of medical therapies, surgical procedures, and facilitation of short term follow-up and post-operative care, all in the first full year of clinical otolaryngology.

The PGY 2 resident is responsible for the evaluation and work-up of all new patients in the outpatient clinic and all inpatient consults under the direct supervision of the clinical faculty. This provides for a focused introduction to the evaluation and management of a broad spectrum of otolaryngologic problems in a one-on-one faculty/resident mentoring environment. Decision making regarding surgical planning begins in the clinic, and the resident is responsible for the preoperative workup and planning. The rotation provides

an early introduction to the intricacies of systems-based practice as the PGY 2 resident is introduced to the global responsibilities of managing an inpatient and outpatient service including scheduling, triage of patients, interaction with the anesthesia service, planning intra-operative airway management, and coordination of appropriate post-operative care. Head and neck cancer patients are evaluated with the head and neck attending and presented by the resident at the VA’s multidisciplinary tumor board. The resident participates in the continuity of care of all patients during postoperative clinic visits.

PATIENT CARE

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. The goals and objectives of the general otolaryngology rotation is described in terms of diagnostic and procedure-oriented learning by PGY year. Mastery of these principles and techniques forms the foundation of competency in patient care in Otolaryngology. Diagnostic oriented learning goals focus on clinical evaluation and work-up, while procedure-oriented learning goals focus on the development of proficiency with both diagnostic and therapeutic procedures in a graduated PGY-level specific fashion. Follow-up and post-operative patient care is strongly emphasized starting with the first PGY year, and an expected mastery of this area by senior resident years is expected. Mastery should be demonstrated by effective patient care and accurate teaching of peri-operative care principles to the junior residents.

Procedural Oriented Learning:

Emphasis is placed on repetition and mastery of the head and neck exam including micro-otoscopy, anterior nasal endoscopy and indirect laryngoscopy. Clinic procedures include flexible and rigid endoscopy of the upper aero digestive tract which is digitally recorded for later review and comparison. Fine needle aspirations, abscess drainage and incisional biopsies are performed in clinic. The operating microscope is used for cerumen disimpactions, mastoid debridement and office myringotomy. Nasal endoscopy is performed for diagnosis, biopsy and postoperative debridement. Fiber optic laryngoscopy is performed for diagnostic and therapeutic purposes. Trans nasally assisted laryngeal biopsies and vocal fold injections are performed in conjunction with attending physicians. The resident is expected to participate in the full range of otolaryngologic operative procedures as first assistant on more complicated cases, and primary surgeon when appropriate. He or she acts as primary surgeon, after an individualized period of mentoring, for operative rigid endoscopy, facial soft tissue defect repair, tonsillectomy, endoscopic turbinoplasty and myringotomy and tube placement. These opportunities depend on each resident’s demonstrated level of preparation and individual experience. When the PGY 2 resident returns to the VA rotation in the second half of the year, after gaining additional surgical experience, there is the

opportunity to participate as surgeon in more advanced procedures such as neck dissections, parotidectomy, thryoidectomy, endoscopic sinus procedures, tympanoplasty, mastoidectomy, laryngoplasty, MOHS defect repairs, septoplasty, rhinoplasty and surgical treatment of obstructive sleep apnea. Due to the one on one intraoperative teaching by attending to the resident, the PGY2, who is appropriately prepared, can perform as surgeon on cases normally reserved for more senior residents. Diagnostic Oriented Learning:

The comprehensive history and head and neck examination, including fiber optic and indirect laryngoscopy, binocular otomicroscopy, and endoscopic nasal examination is mastered on this rotation as the fundamental starting point for all otolaryngologic diagnosis. Familiarity with normal and pathologic findings on each of these examinations is gained with repetition, along with reinforcement by immediate faculty corroboration of findings. Appropriate radiographic, audiometric, balance, swallowing, and laboratory testing is discussed and finalized with the attending physician. Interpretation of imaging studies, audiometric findings, balance testing, swallowing studies, and laboratory studies is taught with close faculty supervision.

MEDICAL KNOWLEDGE

Residents on the Miami VA otolaryngology rotation must demonstrate medical knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. Otolaryngology residents are expected to become familiar with all of the pertinent medical literature relevant to each clinical situation and disease process, and to apply an analytical approach to evaluating each clinical situation. A thorough knowledge of basic science is required as it applies to the normal physiological function of systems related to otolaryngology, but also as it applies to pertinent disease processes affecting these systems. Educational opportunities begin during the first year of residency, with PGY1 residents attending weekly lectures in basic otolaryngology topics prepared and given by senior otolaryngology residents. During the core clinical years of Otolaryngology (PGY 2-5) medical knowledge is disseminated through core curriculum and basic science lectures given throughout the year. AllergyThe resident will spend 6 half days per two month rotation in the VA allergy clinic under the supervision of an attending medical allergist. They will focus on the evaluation, diagnostic workup and treatment of allergic patients including history taking, physical exam, skin testing and pharmacologic and immunotherapeutic management allergic patients.

Audiology/Speech pathologySix half days per two month rotation are spent with the audiology staff learning the theory and practice of audiology and vestibular testing. Residents learn how to interpret

and perform audiograms, impedance testing, ABRs and VNGs. They also participate in cochlear implant and BAHA evaluations. In addition there is a weekly combined ENT/Audiology/Speech pathology conference in which complicated cases are discussed, video strobes and video swallowing studies are reviewed and a treatment plan is formed.

PRACTICE-BASED LEARNING AND IMPROVEMENT Residents on the Miami VA otolaryngology service must demonstrate practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. An electronic portfolio is required of all residents to contain records of, among other areas of competency, clinical scenarios of both favorable and unfavorable patient outcomes from which self directed learning may be demonstrated and utilized well beyond the residency training years. A critical review of current medical literature as it relates to clinical management and ongoing modification of techniques and methods is emphasized on the rotation in the context of patient-specific didactic teaching and dialogue with the Maimi VA otolaryngology faculty. Residents present patients cared for during their VA rotation at the quarterly morbidity and mortality conference where frank and open discussion among residents and faculty serves to assess specific patient treatments and outcomes, with a goal to improve patient care, patient safety, and outcomes. Direct faculty supervision of clinical and operative performance provides the foundation for practice based learning and improvement in a progressive fashion through each post-graduate level. Each resident on the rotation is expected to demonstrate the ability to recognize their own strengths and weaknesses in clinical and surgical skills and decision making with appropriate input from the supervising faculty. Similarly, each resident is expected to show initiative in their efforts to improve weaknesses as measured by demonstrable improvements in clinical decision making and surgical skills.

INTERPERSONAL AND COMMUNICATION SKILLS The Miami VA otolaryngology resident is expected to demonstrate interpersonal and communication skills that result in effective information exchange and learning with patients, their families, and other health professionals. This is particularly true as the VA resident is the sole housestaff representing his service and his patients within the hospital. Demonstration of these skills is monitored in clinical case presentations, observation of the resident’s participation in the informed consent from pre-operative patients, direct observation of resident-patient interactions in the inpatient and outpatient settings, formal conference presentations, as well as in clear and precise medical writing techniques.

PROFESSIONALISM

The Miami VA otolaryngology service resident is expected to demonstrate professionalism at all times, as manifested through a commitment to carrying out

professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Otolaryngology residents are carefully monitored throughout their training to ensure that they demonstrate respect, compassion, and perform with integrity at all levels. Residents at the University of Miami are actively involved with patients and staff from many diverse economic, cultural, religious, and social backgrounds. Faculty provide direct feedback regarding resident interactions with patients, hospital staff, departmental staff, and physicians. Unprofessional behavior, and in particular patterns of behavior, are monitored by both the program leadership and the senior resident leadership such that appropriate interventions may be undertaken. The faculty are responsible for demonstrating ethical and professional behavior at all levels of interpersonal interactions, serving as role models for the housestaff.

SYSTEMS-BASED PRACTICE

The Miami VA otolaryngology resident is expected to demonstrate an understanding of the principles of systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. In addition to didactic lectures on this topic, examples of systems-based practice are highlighted on the Miami VA otolaryngology rotation during interactions between residents and ancillary services or hospital staff to illustrate the concept of the medical care team and the physician’s part in that team. While preparing patients for discharge from the hospital, residents serve as the primary organizers of the complex network of support services needed for postoperative care. Residents facilitate home health needs, outpatient rehabilitation services, and coordination of follow-up care, all within the unique health care delivery system managed by the Veteran’s Administration.

EDUCATIONAL GOALS & OBJECTIVES: RESEARCH ROTATION

The educational program provides a structured research experience sufficient to result in an understanding of the basic principles of study design, performance, analysis, and reporting. At all times during their training, all residents are expected to be involved in research or scholarly activity.  All projects should be conducted with the ultimate goal of publication in a peer-reviewed journal. Every resident obtains or is assigned a mentor from the teaching faculty for each project. The faculty mentor is responsible for providing guidance and supervision of each specific project. Research experiences may involve clinical or basic science research investigations, and should reflect careful advice and planning with the appropriate faculty member. Facilities and protected time for research by the residents are provided, as well as guidance and supervision by qualified faculty.

The research rotation is a four month protected block of time in the PGY 3 year during which the resident is expected to complete a clinical or basic science research project worthy of presentation at a national Otolaryngology or related meeting and publication in a peer reviewed journal.  The resident is prepared for the experience by developing and

writing out his or her research plan in conjunction with their faculty mentor well in advance of their actual research rotation.  This research plan that has been prepared by the resident is presented to the Resident Research Committee, and the faculty reviews and assesses the scientific merit and feasibility of the proposal.  Securing of appropriate regulatory requirements  prior to beginning the study is emphasized, including submission of timely IRB protocols, submission of animal use protocols to the UM internal animal care & use committee, and documentation of compliance with appropriate HIPPA regulations.  The resident is expected to learn the importance of the preparation and planning of their research project, the critical nature of the regulatory oversight of clinical & laboratory animal research, how to pose a testable hypothesis and finally the importance of sound scientific methods in research design.  The techniques of the project will be taught by the faculty mentor and will vary by the nature of the specific project.  Assimilation and analysis of data will be conducted, and this data will be prepared for local presentation at the resident research day.  It is expected that study results will be submitted for presentation and publication at a national meeting, with the resident primarily responsible for manuscript preparation by assuming the role of the first author.  In addition to the long-standing expectation that each resident submits one manuscript per year for publication, a new and added expectation for the 2008-2009 academic year requires that each resident submits a manuscripts for a competitive resident research awards at least once during their residency. It is the goal of the research educational program, and specifically the scientific foundation established during the research rotation, to provide each resident with the capability to fulfill these expectations. 

Specific guidelines for the research rotation are as follows.

Timetable for Proposal Submission

6-12 Months Before Rotation: Consult with faculty members about research interests and choose a mentor Plan a project

4 Months Before Rotation: Submit a written proposal of the research plan to the Resident Research

Committee Modify the research plan as recommended, and submit the final proposal to the

committee within 1 week of your presentation

2-4 Months Before Rotation: With the assistance of faculty mentor, prepare an application to the School's

relevant institutional review board that governs the treatment of animals (Institutional Animal Care and Use Committee) or human subjects (Medical Sciences Subcommittee for the Protection of Human Subjects) for approval of your experimental protocol

Order any special equipment, supplies, or animal subjects that will be required

1 Week Before Rotation:

Prepare laboratory or clinic space and organize equipment needed to perform study

2 Weeks Before End of Rotation: Prepare a short written report and a ten minute oral presentation to the Research

Committee that provides an update on your research progress

2 Months Following Rotation: Submit a written report of project findings to the Research Committee in the

format of a journal publication in consultation with your mentor. Submit an abstract to a national society that sponsors a meeting at which it would be appropriate to present the results of your project.

Research ProposalThe research proposal is modeled after an NIH grant application.1.   Specific Aims:

Brief outline (~1 paragraph) describing the goals of your project, their significance, and how the study will be accomplished. Formulate and present the hypothesis to be tested by the study design.

2.   Introduction: Review the history of the topic Present a detailed review of the critical studies that are most relevant to the

problem Summarize the unanswered questions on this topic that need to be studied Provide the rationale and background information for your choice of experimental

approach and subject3.   Materials and Methods:

describe animal or human subjects to be studied provide a detailed description of the experimental protocol describe the form of the data that will be acquired discuss the equipment that will be used to obtain the data give the method of statistical analysis to be used in the analysis of data and the

value to be used to achieve statistical significance4.   Expected Outcome:

describe how the data will be analyzed discuss how the data address the question posed in the abstract

5.   Schedule of Experiments: outline how your time will be organized to: perform the experiments, analyze

data, write up the results6.   Estimated Budget:

Detail the expected costs including those covering:  purchase and maintenance of experimental subjects, compensation for human subjects, drugs, chemicals, computer supplies, copying, other materials

7. Bibliography

Research Committee Members

Thomas Van De Water, PhD, Chair of CommitteeSimon Angeli, MDAdrien Eshraghi, MDElizabeth Franzmann, MDBrian Jewett, MDXue Liu, MD, PhDDonna Lundy, PhDJose Ruiz, MDZoukaa Sargi, MDGiovana Thomas, MDDonald Weed, MD

Research Expectations and Chandler Society Research Presentation

All residents at the PGY 2 level and above will present their research at the annual Chandler Resident Research Day.  For PGY 2 residents it is hoped that this presentation will form the foundation for the work performed during their PGY 3 research rotation, but an unrelated project may be presented. PGY 4 and 5 residents are encouraged to present follow-up studies related to their PGY 3 research project if these represent substantially new contributions beyond that which has already been presented.  Unrelated projects may also be presented.  Awards are given after critical evaluation of each project by both UM (non-Otolaryngology) and nationally recognized visiting faculty.  Residents are also strongly encouraged to present their work at national meetings and to prepare their findings for publication in peer reviewed journals. Faculty mentors work closely with the residents so that the latter can achieve their research goals.

Each resident and fellow selects a faculty member and a topic for their research presentation at the Annual Chandler Society Research Day.    You need to have chosen a topic and a faculty mentor and submit that information to Dr. Weed by September 1.  An abstract is due by May 1.  Prizes are awarded on Research Day for first, second and third place in the resident category and first prize for the fellow category.  Also, if there are medical and/or graduate students who also completed a research project, they, too, may compete for a first-place prize in the student category.  This will be decided on an as needed basis each year.