Goals and Characteristics
The goal of the Hand Surgery and Microsurgery Fellowship of the Department of Orthopaedic Surgery and its affiliates is to prepare physicians for a career in hand surgery either as clinical surgeons or academic surgeons. It is the goal of the program to recruit outstanding men and women who desire to become leaders in their community or academic programs. The program provides a comprehensive exposure to hand surgery in an integrated program with the UCLA / Orthopaedic Hospital - Department of Orthopaedic Surgery and the Division of Plastic and Reconstructive Surgery at the Ronald Reagan UCLA Medical Center, a university hospital and Level I trauma center; Santa Monica-UCLA Medical Center; Olive View County Medical Center; and Shriners Hospital. This provides a high volume and diverse spectrum of acute trauma, post-traumatic reconstruction, congenital anomalies, and reconstruction of the arthritic hand, wrist, and elbow. In addition to replantation, residents/fellows will gain experience in microsurgical reconstruction for limb salvage of malignant tumors, pediatric hand reconstruction, and soft-tissue and bony reconstruction of the extremities. Residents/fellows receive individual teaching and supervision in the operating room and outpatient clinics. Fellows are given junior faculty appointments and admitting privileges, and can progressively develop independent responsibility for patient care and supervision of residents. Weekly teaching conferences, journal club, and anatomical dissections of the upper extremity provide a strong academic environment. The program provides fellows with the opportunity to experience clinical research and to present that research either at local gatherings or at national meetings.
It is the goal of the program to have residents/fellows understand the practice of hand surgery and to provide ethical lessons through faculty example and discussion. It is our goal for the resident/fellow to be competent in the knowledge of the practice of hand surgery, to carry out this practice in a professional and ethical manner, to develop skills for continuing and self-reflective education in the field of hand surgery, and to understand hand surgery in the context of the healthcare system in which they will practice. It is anticipated that the resident/fellow will be competent in the objectives as outlined on the UCLA orthopaedic website, www.ortho.ucla.edu.
In summary, the goals of the fellowship program for the Department of Orthopaedic Surgery are to provide our resident/fellow staff with an environment for education and practice that encourages excellence in preparation for their careers in clinical or academic medicine.
Objectives and Required Competencies For Fellow Education
Listed below are the required competencies for the hand surgery fellows rotating on the UCLA Hand Surgery Service. The competencies are listed in the format of what the hand fellow is expected to accomplish during his/her fellowship on this service.
Each hand surgery fellow (PGY 6 or higher) within the UCLA / Orthopaedic Hospital - Department of Orthopaedic Surgery is assigned a twelve-month rotation on the Hand Surgery Service. Six months are spent under the primary direction of Dr. Prosper Benhaim, while the other six months are spent under the primary direction of Dr. Kodi Azari. The UCLA Hand Surgery Service is somewhat unique in that there is only a single hand service that is based in several different clinical settings designed to maximize fellow exposure to a wide variety of patients, insurance types, diagnoses, age ranges, and cultural backgrounds.
The primary UCLA/Westwood location is a level I trauma center and tertiary referral hospital that allows exposure to a large volume of trauma patients, complex hand surgery problems, secondary reconstructive challenges, and worker's compensation patients. All primary attendings (Drs. Azari, and Benhaim) and affiliated attendings (Drs. Ghiassis and Meals) see patients in offices at the UCLA site, with Meals and Ghiassi offering a private practice setting as opposed to the clinic setting offered by Drs. Benhaim and Azari. All practices include a combination of routine "bread and butter" patients and complex reconstructive patients. The UCLA site has a significant population of student athlete patients that we treat in association with the many athletic programs and busy sports medicine programs here at UCLA. The UCLA site serves a wide variety of patient types in terms of background, education, level of sophistication, and insurance coverage (worker's compensation, PPO, HMO, Medicare, MediCal, self-pay). Doctors Ghiassi and Meals also offer special expertise in elbow surgery.
The Santa Monica-UCLA site is attended primarily by Dr. Azari, with a primarily HMO patient population with a variety of hand surgery problems. Dr. Benhaim will participate in complex reconstructions at the Santa Monica site with regard to a variety of patients with upper extremity tumors, in conjunction with the UCLA orthopedic oncology service based at Santa Monica.
Olive View-UCLA Medical Center is a level II trauma center under the auspices of Los Angeles County as a "county hospital" that services a very large number of indigent patients in San Fernando Valley. In addition to a routine hand surgery problems, patients at Olive View present with rather complex secondary reconstructive problems, including an often-delayed presentation for trauma to the hand and wrist (e.g. we routinely see distal radius fractures that present 4-6 weeks after injury, thereby presenting a significantly more complicated treatment challenge). The patient population at Olive View is quite different than at UCLA and Santa Monica-UCLA, including an extremely diverse cultural mix (predominantly Hispanic, but quite varied), often indigent and usually without health insurance of any sort. This site teaches the fellow how to negotiate effective care for indigent uninsured patients in a county hospital setting, highlighting for them a number of systems-based issues, cultural differences and language barriers that need to be overcome to ensure that timely and effective care is provided for the patients being served. Both Dr. Azari and Dr. Benhaim attend at the Olive View hospital for both surgery and clinics, providing rich opportunities for fellow education.
Shriners Hospital offers the fellow exposure to a variety of congenital hand problems, focusing on microsurgical reconstruction (e.g. toe-to-hand transfers) and reconstructive surgery for congenital anomalies (e.g. index finger pollicization procedures).
The goals and objectives for the hand surgery fellow are the same at each site, but the uniqueness of each site, as emphasized above, allows the fellow to gain a diversified experience in each of these settings. The fellow will be able to practice in nearly any setting after graduating from this program, including academic practice, private practice, county/government hospital, HMO environment, and worker's compensation.
I. Patient Care
The fellow will:
- Demonstrate appropriate evaluation and treatment of patients with hand surgery problems in the emergency room and as part of the inpatient consultation service, including application of physical examination tests specific to the diagnosis.
- Be able to examine the injured hand with a high level of sophistication and detail to determine any bony or ligamentous injury, flexor or extensor tendon injury, nerve injury, arterial injury, and infections of the upper extremity.
- Be able to perform a detailed clinical examination of the forearm and wrist.
- Be able to order appropriate diagnostic tests and imaging studies to assist with diagnosis and accurate assessment of the level/severity of the injury.
- Be able to initiate and interpret a logical course of investigations for patients complaining of chronic wrist pain, including bone scan, arthrogram, CT scan and MRI scan of the wrist.
- Be able to interpret x-rays of fractures of the wrist and hand to determine the need for closed reduction or admission for open reduction and internal fixation.
- In consultation with the appropriate hand surgery attending, provide treatment for the patient as appropriate for level of training as a hand surgery fellow.
- Be able to treat both simple and complex infections of the hand, wrist and forearm (e.g. flexor tenosynovitis, large or complex abscess, deep space infections of the hand, complicated cellulitis requiring inpatient therapy, necrotizing fasciitis, etc.).
- Be able to reduce and apply appropriate cast immobilization for displaced or angulated fractures of the metacarpals, phalanges and distal radius.
- Be able to repair nail bed injuries or apply split thickness or full thickness skin grafts for fingertip injuries.
- Be able to perform steroid injections of the A1 pulley of the flexor tendon sheath for trigger fingers, first dorsal extensor compartment for deQuervain's tenosynovitis, lateral/medial epicondyle for epicondylitis, and carpal tunnel for carpal tunnel syndrome.
- Demonstrate a thorough understanding of the operative anatomy and be able to perform at least the following procedures:
- Open reduction and internal fixation of metacarpal and phalangeal fractures using K-wires, interosseous wires, interfragmentary and/or lag screws, and screws and plates.
- Repair/reconstruction of ligament injuries in the hand (e.g. repair of thumb MP joint ulnar collateral ligament rupture).
- Carpal tunnel release, radial tunnel release, cubital tunnel release, and radial tunnel release.
- Open reduction and internal fixation of scaphoid fractures.
- Russe bone graft, distal radius bone graft, iliac crest bone graft, and vascularized bone graft for scaphoid nonunions.
- Release of Dupuytren's contracture, including needle aponeurotomy.
- Arthrodesis of interphalangeal joints.
- Understand the operative approach to the digits (Bruner approach).
- Dorsal and volar approaches to the wrist joint, including open reduction/internal fixation vs. closed reduction/percutaneous K-wire fixation of distal radius fractures.
- Treatment of ulnar shaft fractures.
- Wrist arthroscopy.
- Limited intercarpal fusions (e.g. STT fusion, four-corner fusion).
- Proximal row carpectomy.
- Complete wrist fusion.
- Syndactyly release and treatment of other common congenital hand differences.
- Lateral/medial epicondylectomy for epicondylitis.
- Tendon transfers.
- Radius and ulna shortening osteotomies.
- Distal ulna resection procedures (e.g. Darrach procedure, Feldon wafer procedure, Bower's hemiresection).
- Trapezium excisional arthroplasty for metacarpal-trapezial arthritis.
- Extensor tendon repairs.
- Flexor tendon repairs, including "no man's land" repairs for zone II flexor tendon injuries.
- Tenolysis, secondary tendon reconstruction, flexor tendon sheath pulley reconstruction.
- Extensor and flexor tendon grafting.
- Joint arthroplasties of the MP and PIP joints.
- Excision of upper extremity tumors.
- Excision of common hand masses (giant cell tumor, ganglion cysts, mucous cysts, volar retinacular cysts, neuromas, schwannomas, etc.)
- Be able to apply an external fixator for reduction of distal radius fractures.
- Demonstrate microsurgical skills under the operating microscope and be able to perform microsurgical procedures such as arterial anastomoses, group fascicular nerve repair, nerve grafting and free tissue transfers.
II. Medical Knowledge
The fellow will:
- Develop an advanced understanding of the anatomy of the forearm, wrist and hand, including the bones, ligaments, tendons, nerves and arteries.
- Demonstrate a thorough understanding of the treatment of fractures of the hand and wrist, fingertip injuries, tendon injuries, nerve injuries.
- Demonstrate ability to diagnose and treat nerve compression syndromes, including carpal tunnel syndrome, cubital tunnel syndrome and radial tunnel syndrome.
- Understand the indications and contraindications for replantation in the upper extremity.
- Be able to perform reconstructive hand surgery, including treatment for congenital hand anomalies, tendon transfers and Dupuytren's contracture.
- Read and demonstrate a detailed understanding of the material contained within:
- Examination of the Hand, published by the American Society for Surgery of the Hand.
- The entire text of The Hand: Diagnosis and Indications, by Paul Smith, M.D.
- Applicable chapters of Green's Operative Hand Surgery textbook before each elective operative case for which the fellow expects to participate.
- Focused reading of other appropriate textbooks and journals of hand surgery, as indicated.
- Incorporate online sources of information available on the internet to augment the knowledge base and to facilitate acquiring specific information for specific questions or problems that arise.
- Demonstrate a detailed understanding of the use of splints for fracture immobilization and tendon rehabilitation.
- Prepare and present at least three 45-minute presentations on three different hand surgery topics at the weekly hand service conference during the rotation (over a twelve-month period).
- Prepare and present a monthly report for the hand surgery Morbidity and Mortality conference, including a detailed presentation of "Cases of the Month".
- Attend and participate at the weekly hand service conference during the rotation.
- Attend the orthopaedic residents' journal club that focuses on hand surgery, hosted 2-3 times per year by Drs. Azari, Meals and Benhaim.
- Attend and participate at the biannual lecture series on hand surgery (24 lectures total), presented at the weekly orthopaedic surgery basic science course on Wednesday mornings.
- Attend the monthly hand surgery journal club, hosted by Dr. Meals at his home.
III. Practice-Based Learning and Improvement
The fellow will:
- Frequently use, in a focused fashion, the available printed textbooks (in the orthopaedic library, in Dr. Benhaim's office, and in Dr. Meals' office), online textbooks, and Medline sources for application to specific patients. The goal is to demonstrate the ability to locate and interpret scientific studies and known medical knowledge into an appropriate knowledge base that will be of direct benefit to patients.
- Frequently present and discuss patients with the attending hand surgeons after initial evaluation and review of available diagnostic tests to confirm the appropriate treatment plan. The hand fellow will be expected to formulate a plan of treatment, which will then be reviewed in detail and either confirmed or altered as necessary to achieve optimal patient outcome.
- Use appropriate sources (e.g. textbook, selected articles from the literature, etc.) to obtain more detailed information about a specific patient or diagnosis, based on his/her experiences on the hand surgery service and any specific questions that arise as part of that experience/exposure.
- Play an active role in the teaching of senior orthopaedic surgery residents, junior plastic surgery residents, junior orthopaedic residents, sports medicine fellows, senior medical students (sub-interns) and junior medical students on the service.
- Demonstrate expertise in use of available information technology and hospital information systems to manage patient data (e.g. lab tests, imaging tests, etc.) and access online information that will be of direct benefit to his/her own education.
- Integrate feedback from faculty to ensure that the hand fellow is able to analyze his/her own practice experience, with the goal of improving future patient care. Feedback is provided systematically at the weekly hand service conference, which includes a morbidity and mortality format to identify areas of potential improvement for all members of the hand surgery service.
- Undergo formal evaluation at least twice per year, including review of progress and suggestions for improvement by the Chief of the service (Dr. Benhaim).
IV. Interpersonal and Communication Skills
The fellow will:
- Demonstrate ability to communicate effectively with all members of the hand service, including medical students, junior residents, senior residents, sports medicine fellows, and hand surgery attending staff.
- Demonstrate ability to communicate effectively and work well with all members of the hospital staff, including nurses, nursing assistants, radiology staff, social workers, discharge planners, physical therapists, hand therapists, operating room/surgery center staff, inpatient/outpatient support staff, etc.
- Demonstrate the ability to interact effectively, professionally, and empathetically with patients and family members.
- Demonstrate the ability to provide appropriate and detailed information to patients and family members, when appropriate.
- Demonstrate the ability to develop an appropriate relationship with a patient that fosters communication, respect, and ethics of the highest degree.
- Demonstrate the ability to recognize important cultural and generational differences that may affect patient care, and to apply appropriate changes in approach to these patients that respect these important differences (e.g. amputation of a digit in Asian cultures has important cultural implications that need to be addressed).
- Demonstrate effective listening and communication skills with patients, which may include both verbal and non-verbal skills.
- emonstrate ability to understand and respond appropriately to patient inquiries.
The fellow will:
- Demonstrate a strict adherence to medical/ethical principles.
- Demonstrate a keen sensitivity to the differences and challenges that a diverse patient population may present, especially in the context of the known multi-racial and multi-cultural patient population in the Los Angeles area.
- Treat all patients with respect, empathy, and with compassionate care. All patient inquiries and requests will be considered seriously, professionally, and in a timely manner.
- Recognize the important social, economic, emotional, and work-related implications that a hand problem or injury may represent for the patient.
- Provide patients with excellent care in all aspects.
- Maintain patient confidentiality, including strict adherence to HIPPA guidelines.
- Obtain informed consent from patients in accordance with established guidelines that ensure full patient comprehension after a detailed discussion of all pertinent issues relating to patient care/surgery. This includes the opportunity for the patient to ask and have answered questions relating to any proposed procedures.
- Demonstrate the ability to accommodate and adapt to differences in patients' culture, age, gender and disabilities.
VI. Systems-Based Practice
The fellow will:
- Develop an awareness of how the care that they provide to patients can affect other caregivers and even the UCLA Medical Center in general.
- Demonstrate an ability to effectively utilize hospital resources in a way that directly benefits patient care.
- Develop a more in-depth understanding of the different types of medical practice available in the context of hand surgery. This will include exposure to care in different settings, such as UCLA private attending clinics, Santa Monica-UCLA Medical Center, Olive View-UCLA County hospital, Shriners Children's Hospital, and hand surgery clinic run by the hand fellow.
- Develop a more detailed understanding of the differences in different payor types, such as worker's compensation, managed care, HMO, PPO, Medicare, MediCal, and student health insurance plans.
- Develop a mature understanding of the necessity to provide efficient and cost-effective health care in the context of appropriate use of limited medical resources, yet without sacrificing quality of care.
- Act as a patient advocate and assist patients in obtaining the necessary care, including coordination of post-discharge care if necessary (e.g. home health care, postoperative hand therapy, placement into appropriate rehabilitation facility, etc.).