Objectives and Required Competencies for the Orthopaedic RII and RIV and the Postgraduate
Introduction: The Orthopaedic Oncology rotation is designed to introduce, educate and train postgraduate fellows and the residents in the diagnosis and management of musculoskeletal oncology disorders and tumor like conditions of bone and soft tissues. Administrative, clinical and surgical responsibilities are assigned according to the level of training. This is a tertiary/quaternary referral service with patients seen in the outpatient clinic, as inpatient consults and in the emergency room, generally as pathologic fractures.
I. Patient Care: (PGY 4 and 2)
1. Residents at both levels and the postgraduate fellow are expected to learn and demonstrate the ability to do a complete history and physical exam of patients presenting in clinic or on the consult service with musculoskeletal conditions. (Enclosure 1) All new patient workups will be forwarded to me for review and an addendum.
2. Residents at both levels and the postgraduate fellow are expected to learn and understand the appropriate laboratory workup and diagnostic tests best suited for patients with musculoskeletal tumor and tumor-like conditions. This includes the appropriate extent of disease staging studies for those patients with primary bone and soft tissue malignancies, as well as what situations are better evaluated by a CT scan vs. an MRI.
3. Residents and the postgraduate fellow will participate in the informed consent process and learn how to comprehensively and appropriately outline and document the risks and alternatives to the recommended surgical procedures or the medical management plan.
4. Residents at both levels are responsible for the day-to-day care of the patients on the inpatient service. This includes a daily resident inpatient note, outlining the progress, problems and management plans. It also includes the timely dictation, review and signing of discharge summaries, which are to be forwarded to me for review and addendum. This also includes properly informing the patient of their discharge instructions, restrictions, medication doses and durations including anticoagulation orders, as well as the exact follow-up date. The postgraduate fellow is to supervise the residents, assist and instruct them in all aspects of the care of the oncology patient.
5. The fellow and both residents will participate to their level and training and ability in the surgical management of the musculoskeletal tumor patients. The primary resident or fellow involved in the case is responsible for contacting the patient's family or representative immediately upon stabilizing the patient in the recovery room.
6. The postgraduate fellow is responsible for procuring and reviewing with me the preoperative diagnostic studies (x-rays, CTs and MRIs) the day prior to the planed surgical event. In addition the postgraduate fellow is responsible for procuring and organizing the pertinent diagnostic studies for the weekly Thursday afternoon Multidisciplinary Musculoskeletal Tumor Board. When a fellow is not available these functions will be the responsibility of the senior resident (PGY 4).
7. The post graduate fellow is responsible to teach, instruct and supervise the residents and medical students in all aspects of the surgical and clinical care of the oncology patient. The senior resident (PGY 4) will be responsible to teach and supervise the junior resident (PGY 2) and medical students both in the clinic and in the operating room. This includes reviewing postoperative orders as well as appropriate surgical techniques.
II. Medical Knowledge:
1. The fellow and both residents, after reviewing an anatomy book of their choosing, are to be able to discuss and identify the anatomical structures involved in each planned surgical procedure.
2. The fellow and all residents will be given their own binder with the recent AAOS Instruction Course Lectures on musculoskeletal tumor and tumor-like conditions. Included are other materials that I have written on specific subjects. Loaned to each resident while on the service will be the AAOS Orthopaedic Update on Tumors to be used while on this rotation. These two sources are to be read and studied on the 2-month rotation. They should be able to demonstrate knowledge on the disease entities on all surgical cases.
3. When presenting newly evaluated patients in the clinic or on the consultation service the fellow and the residents are expected to demonstrate knowledge of specific disease entities and the treatment options.
4. The fellow and both residents are to attend the weekly Musculoskeletal Tumor Board, which meets every Thursday afternoon at 3:30 pm.
5. The fellow and both residents are to understand the following basic concepts and applications:
MSTS (Musculoskeletal Tumor Society)
Staging and Grading Classification
IA
IB
IIA
IIB
III
Classification of surgical margins and procedures:
Incisional
Marginal
Wide
Radical
Local control and reconstruction options for malignant bone tumors:
Amputation
Resection arthrodesis
Allograft or allograft composite reconstruction
Endoprosthesis reconstruction
Rotationplasty
Benign Tumors: Understand the demographic, clinical presentation, pathophysiology, radiographic evaluation and the current treatments.
Cartilage origin:
Enchondroma
Osteochondroma
Chondroblastoma
Chondromyxoidfibroma
Periosteal chondrom
Bone Origin
Osteoid ostoma
Osteoblastoma
Fibrous origin
Non-ossifying fibroma
Fibrous cortical defect
Desmoid tumor of bone (grade ½ fibrosarcoma)
Osteofibrous dysphasia (Campanacci's disease)
Vascular origin
Hemangioma of bone
Neural origin
None
Cell of unknown origin
Giant cell tumor
Tumor-like conditions of bone: Understand the demographic, clinical presentation, pathophysiology, radiographic evaluation and the current treatments. These are non-neoplastic conditions, which can be confused true tumors.
Aneurismal bone cyst: a reactive process in bone
Osteomylitis; bacterial, fungal and TB
Stress fracture
Avulsion apophysitis
Myositis ossificans
Synovial chondromatosis and osteochondromatosis: a metaplasia of synovium
Fibrous dysphasia: a bone dysphasia
Langerhans granulomatosis (eosinophillic granuloma)
Malignant bone tumors: Understand the demographic, clinical presentation, pathophysiology, radiographic evaluation and the current treatments.
Cartilage sarcomas: Surgery alone
Spindle cell sarcomas(OGS, MFH):Chemotherapy and surgery
Round cell tumors (Myeloma, Lymphoma, Ewing's Sarcoma): Chemotherapy, radiation and surgery
Bone Origin: Osteosarcoma
Standard high-grade osteosarcoma
Paroateal OGS: OGS Low grade I osteoblastic OGS
Periostesal OGS: Grade 2-¾ chondroblastic OGS
Telangetatic OGS: Vascular and always high-grade
Treatment (RT) associated OGS: high-grade
Illness associated (Paget's disease) OGS: high-grade
Cartilage origin: Chondrosarcoma
Primary Chondrosarcoma
Secondary CS (from an enchondroma or Osteochondroma)
Dedifferentiated CS (high-grade spindle cell component) Rx like OGS: Chemotherapy and surgery
Hematopopetic cell of origin:
Myeloma
Lymphoma
Plasmacytoma (myeloma precursor)
Cell of unknown origin: Ewing's Sarcoma
Neural crest: Chordoma
Other: Adamantanoma
Soft tissue tumors: Understand the demographic, clinical presentation, pathophysiology, radiographic evaluation and the current treatments.
Benign soft tissue tumors and tumor like conditions:
Lipoma
Myxoma
PVNS
Hemangioma
Ganglion
Muscle herniation
Malignant soft tissue sarcomas:
Liposarcoma
Synovial sarcoma
MFH
Epitheloid Sarcoma
Clear cell sarcoma of tendons and aponeuroses
Skin malignancies:
Basal cell carcinoma
Melanoma
Squamous cell carcinoma
Dermatofibrosarcoma protuberans
Metastatic tumor to bone: Understand the demographic, clinical presentation, pathophysiology, radiographic evaluation and the current treatments. Realize that the natural history of each tumor is different and the management will therefore vary.
Breast
Lung
Renal
Prostate
Thyroid
Myeloma is frequently treated as a metastatisis to bone
6. Surgical skills: It is anticipated that the RIV know and do everything the RII is expected to know but in greater detail, understanding and proficiency.
Understand the technique and perform an open biopsy of bone and soft tissue
Perform an iliac crest graft
Perform excisions of osteochondromas
Perform curettage and bone graft of benign bone tumors
Perform and assist in amputations: BKA with posterior flap and an AKA with a myodesis
Assist in higher amputation
Perform resections of low-grade soft tissue tumors.
Assist in the resection of high-grade soft tissue sarcomas
Assist in limb salvage surgeries of bone
7. Surgical skills: In addition to becoming competent in all surgical techniques in the preceding paragraph #6. The fellow is expected to become surgically skilled in all aspects of limb-sparing surgery and in the major amputations: shoulder and hip disarticulation, forequarter and hemipelvectomy amputations.
III. Practice-Based Learning and Improvement:
1. The goal is to have the residents learn and demonstrate how to use the available texts, references and intern resources to develop an appropriate medical knowledge base that will be directed toward patient care.
2. The residents and fellow will be expected to formulate treatment plans based upon their accumulated knowledge of personal study as well as the day-to-day interactions with myself, chief residents of fellows during the evaluation of clinic patients, surgical cases and from the consult service. Feed back to the residents from me is an ongoing daily exercise in the clinic, wards and in the OR.
3. The fellow and the residents are expected to play an integral role in the education of more junior residents, interns and medical student who rotate on the service.
4. An open book test is given to the residents at the beginning of the rotation to guide the personal study, and may be administered as a defined test at the conclusion of the rotation. (Enclosure 2)
5. In addition to the daily feedback given to the fellows and residents, a formal review of their progress is made at the completion of the rotation. This is prepared by the department, filled out by the attending and discussed with each resident as he or she leaves the service.
IV. Interpersonal and Communication Skills:
1. The residents and the fellow are expected to demonstrate effective communication skills between themselves, senior residents, fellows and attending alike.
2. Residents and the fellow are also to demonstrate appropriate communication skills between themselves, paramedical employees, and medical students.
3. The residents and fellow need to develop appropriate communication skills and professional relationships with the patient and family members. These need to honest and open relationships that foster understanding and trust. They need to show respect and understanding for cultural, religious and generational differences and issues. This is especially is very critical on the oncology service.
4. The residents and the fellow must demonstrate good listening abilities and show that they are responsive to the needs of the patients, their families, as well as to the medical staff.
V. System -Based Practice:
1. Patients seen our outpatient clinic have already been approved by their health management provider for consultation and surgery. The residents and fellows still need to develop an understanding of the different types of payor plans such as worker's compensation, private insurance, Medicare, HMO plans, PPO plans, Medical and CCS. They need to get a feel for not about the amount payment per se, but the various rules that allow us to capture the patient to afford them what we believe is the best tertiary and quaternary medical care in the region.
2. The residents and fellow need to learn and be conscious of the necessity to provide both efficient but also cost-effective care with appropriate use of limited medical resources without compromising the quality of care.
3. The residents and fellow need to demonstrate the effective use of hospital resources, utilizing them in a cost effective method and in a way that directly benefits the patient.
4. The residents and fellow need to become the patient's advocate and assist them in obtaining the best quality of care while at the same time working with the health manage groups to utilize those resources where and when ever possible. This can require personal calls to the primary care physicians or the plan's medial director to cordially explain the situation and why they plan should approve the care you have requested at our institution.
5. If patients cannot get access to care within our program it is incumbent to see if we can get them cared for at other institutions within our system if possible: The Veterans hospital, the Shriner's Hospital or our county facility.
VI. Professionalism: Professionalism is especially important with patients who have oncology issues. A quote from W. Somerset Maugham's "Of Human Bondage" (1915) sums it up. When a turn of the century (1900) physician was asked why he always put on his white collar before seeing a patient, his response was: "Sometimes, that is all I have to offer them."
1. While professionalism is an important part of every Orthopaedic subspecialty area, it takes on a more critical role in the oncology or prospective oncology patient where the issues are immediately focus on the real concern of the potential loss of limb or loss of life; and some patients will lose their extremity and/or their life.
2. These concerns make most if not all oncology issues emergencies, at least in the patient's mind. In addition, many patients have been symptomatic for some time and have become frustrated by a medical system that in many cases in not very responsive to their complaints or needs (delay in diagnosis). Further it is not uncommon that they have been told, incorrectly, that they have a cancer and that they will need an amputation or that they are going to die. To say the least, these patients are among the most emotionally charged. It is therefore so critical that all members of the team present themselves and comport themselves in the most professional manner as this will help mitigate inappropriate anxieties and induce confidence.
3. Professionalism includes proper attire; look sharp and be squared away. Be courteousness and show respect, empathy and understanding. Maintain strict adherence to patient confidentiality along HIPPA guidelines. Be sensitive to differences in the patient's culture, gender, age and disabilities. It requires the ability to listen to what the patient has to say. Most everything is in the history, which is then followed by a complete and thorough physical exam, keeping the patient properly draped and being sensitive to modesty issues. Then the diagnostic studies are reviewed.
4. Professionalism comes to bear when giving informed consent. You need to be able to inform the patient correctly and accurately of the potential risks and problems, putting them in perspective of their age and urgency of the recommended surgical treatment, yet without unduly distressing them. To do this the doctor-patient relationship has to have been well established, hence the need for the operating surgeon to do this consent. Informed consents on the Orthopaedic Oncology Service are obtained with the residents present and are dictated as part of my consultation note. It also appears again in the operative note under "Indications and Consent for Surgery" at he beginning of the operative dictation. It includes the following language as well as additional comments as a specific procedure necessitates:
"Any surgical procedure carries with it the risks of loss of limb or loss of life. Medical complications include but are not limited to death or disability from a heart attack, stroke, GI bleed, thrombophlebitis and pulmonary embolism, sepsis, adverse reactions (death) due to blood transfusions, allergy or adverse drug interaction. There are other rare, unknown and uncommon systemic conditions that could also adversely affect the systemic outcome. Local complications include but are not limited to wound dehiscence, deep infection, failure of fixation or reconstruction, local recurrence as well as other rare, uncommon and unknown local complications that may necessitate re-operation, more complex orthopaedic reconstructions or amputation. The patient was informed, his or her questions were answered, and the consents were signed."
5. Professionalism again remains paramount when patients present with inoperable conditions and when death from the condition is a certainty. Alternatively if in the course of a patients care a limb-sparing procedure fails or the disease process progresses and becomes unresponsive to systemic treatment, with death the eventual outcome; professionalism is critical. The patient and family need, after careful explanation, to be assured that they have had the best of care, the best that modern medicine that this tertiary / quaternary program can deliver. Their only consolation is to believe that they have had the very best shot at survival. The absence of professionalism anywhere along the line precludes the successful delivery and acceptance of this message, increasing their anguish and the tragedy of their death. Cancer is always as an unwanted, untimely and most assuredly undeserved interloper. These patients deserve our very best. Professionalism is sometimes all we have to offer them.
