Listed below are the required competencies for the residents rotating on the UCLA Hand Surgery Service. The competencies are listed in the format of what the resident is expected to accomplish during his/her rotation on this service.
A junior resident within the UCLA / Orthopaedic Hospital - Department of Orthopaedic Surgery will perform a one-month rotation on the Hand Surgery Service, either in the R-II or R-III year.
I. Patient Care
1. 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.
2. Be able to examine the injured hand to determine any bony or ligamentous injury, flexor or extensor tendon injury, nerve injury, arterial injury, and infections of the upper extremity.
3. Be able to order appropriate routine diagnostic tests and imaging studies to assist with diagnosis and accurate assessment of the level/severity of the injury.
4. 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.
5. In consultation with the senior resident, hand fellow or attending, provide treatment for the patient as appropriate for level of training (e.g. treatment of fingertip injuries in the emergency room, closed reduction of distal radius fracture).
6. Be able to treat simple infections of the hand on an outpatient basis (e.g. paronychia, felon, uncomplicated cellulitis).
7. Be able to reduce and apply appropriate cast immobilization for displaced or angulated fractures of the metacarpals, phalanges and distal radius.
8. Be able to repair nail bed injuries or apply split thickness or full thickness skin grafts for fingertip injuries.
9. Be available to participate in outpatient surgical procedures with Dr. Meals every Thursday morning, including demonstration of appropriate surgical skills necessary to perform outpatient surgical procedures (e.g. trigger finger release, carpal tunnel release, first dorsal extensor tendon compartment release for deQuervain's tenosynovitis, excision of ganglion cysts, excision of simple benign tumors of the upper extremity, ORIF of hand fractures, repair of extensor tendon injuries, etc.).
10. Be able to harvest bone graft from the iliac crest, plantaris/palmaris tendon graft, and sural nerve graft from the lower leg.
11. Assist in more complicated traumatic and reconstructive hand surgery procedures.
II. Medical Knowledge
1. Develop a basic understanding of the anatomy of the forearm, wrist and hand, including the bones, ligaments, tendons, nerves and arteries.
2. Understand the treatment of fingertip injuries, fractures of the hand and wrist, extensor and flexor tendon injuries, and nerve injuries.
3. Understand the indications and contraindications for replantation in the upper extremity.
4. Read:
A. Examination of the Hand, published by the American Society for Surgery of the Hand.
B. The first chapter (100 pages) of The Hand: Diagnosis and Indications by Paul Smith, M.D.
C. Applicable chapters of Green's Operative Hand Surgery textbook before elective operative cases on Thursday mornings, for which the resident is expected to participate.
5. Prepare and present one 45-minute presentation on an assigned hand surgery topic at the weekly hand service conference during the rotation.
6. Attend and participate at the weekly hand service conference during the rotation.
7. Attend the orthopaedic residents' journal club that focuses on hand surgery, hosted 2-3 times per year by Drs. Jones, Meals and Benhaim.
8. Attend the biannual lecture series on hand surgery (24 lectures total), presented at the weekly orthopaedic surgery basic science course on Wednesday mornings.
III. Practice-Based Learning and Improvement
1. Frequent, yet focused, use of available printed textbooks (in the orthopaedic library and in Dr. Benhaim's 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.
2. Frequent discussion with senior residents, hand fellows, and attending surgeons to present patients after initial evaluation, review available diagnostic tests, and to confirm the appropriate treatment plan. The resident 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.
3. Use of 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.
4. Play an active role in the teaching of interns, senior medical students (sub-interns) and junior medical students on the service.
5. 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.
6. Integrate feedback from faculty and hand surgery fellows to ensure that the junior resident is able to analyze his/her own practice experience, with the goal of improving future patient care. Feedback to the junior resident 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.
IV. Interpersonal and Communication Skills
1. Demonstrate ability to communicate effectively with all members of the hand service, including medical students, senior residents, hand fellows, and hand surgery attending staff.
2. 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.
3. Demonstrate the ability to interact effectively, professionally, and empathetically with patients and family members.
4. Demonstrate the ability to provide appropriate and detailed information to patients and family members, when appropriate.
5. Demonstrate the ability to develop an appropriate relationship with a patient that fosters communication, respect, and ethics of the highest degree.
6. 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).
7. Demonstrate effective listening and communication skills with patients, which may include both verbal and non-verbal skills.
8. Demonstrate the ability to understand and respond appropriately to patient inquiries.
V. Professionalism
1. Demonstrate a strict adherence to medical/ethical principles.
2. 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.
3. 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.
4. Provide patients with excellent care in all aspects.
5. Maintain patient confidentiality, including strict adherence to HIPPA guidelines.
6. 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 or operations.
7. Demonstrate the ability to accommodate and adapt to differences in patients' culture, age, gender and disabilities.
VI. Systems-Based Practice
1. Develop an awareness of how the care that they provide to patients can affect other caregivers and even the UCLA Medical Center in general. The resident must recognize that he/she is a representative of UCLA Medical Center, and must act in accordance with UCLA guidelines for patient care.
2. Demonstrate an ability to effectively utilize hospital resources in a way that directly benefits patient care.
3. Begin to develop a basic understanding of the different types of medical practice available in the context of orthopaedic hand surgery.
4. Understand the basic differences in different payor types, such as worker's compensation, managed care, HMO, PPO, Medicare, MediCal, and student health insurance plans.
5. Begin to develop an 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.
6. 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.).
Each senior (5th clinical year) resident within the UCLA / Orthopaedic Hospital - Department of Orthopaedic Surgery is assigned a two-month rotation on the Hand Surgery Service.
I. Patient Care
1. 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.
2. 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.
3. Be able to perform a detailed clinical examination of the forearm and wrist.
4. Be able to order appropriate diagnostic tests and imaging studies to assist with diagnosis and accurate assessment of the level/severity of the injury.
5. 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.
6. 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.
7. In consultation with the hand fellow or attending, provide treatment for the patient as appropriate for level of training as a senior resident.
8. Be able to treat more 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, etc.).
9. Be able to reduce and apply appropriate cast immobilization for displaced or angulated fractures of the metacarpals, phalanges and distal radius.
10. Be able to repair nail bed injuries or apply split thickness or full thickness skin grafts for fingertip injuries.
11. 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, and carpal tunnel for carpal tunnel syndrome.
12. Understand the operative anatomy and be able to perform the following procedures:
a. Open reduction and internal fixation of metacarpal and phalangeal fractures using K-wires, intraosseous wires, and screws and plates.
b. Flexor tendon repair in "no man's land".
c. Carpal tunnel release and cubital tunnel release.
d. Open reduction and internal fixation of scaphoid fractures.
e. Russe bone graft for scaphoid nonunions.
f. Release of Dupuytren's contracture.
g. Arthrodesis of interphalangeal joints.
h. Understand the operative approach to the digits (Bruner approach).
i. Dorsal and volar approaches to the wrist joint, including open reduction/internal fixation vs. closed reduction/percutaneous K-wire fixation of distal radius fractures.
13. Be able to apply an external fixator for reduction of distal radius fractures.
14. Practice microsurgical skills under the operating microscope and be able to assist in microsurgical procedures such as arterial anastomoses, group fascicular nerve repair, and nerve grafting.
15. Be able to assist in more complicated reconstructive hand surgery procedures such as congenital hand reconstruction, tendon transfers, neurolyses and tenolysis.
II. Medical Knowledge
1. Develop an advanced understanding of the anatomy of the forearm, wrist and hand, including the bones, ligaments, tendons, nerves and arteries.
2. Demonstrate a thorough understanding of the treatment of fractures of the hand and wrist, fingertip injuries, tendon injuries, nerve injuries.
3. Understand in detail the diagnosis and treatment of nerve compression syndromes, including carpal tunnel syndrome, cubital tunnel syndrome and radial tunnel syndrome.
4. Understand the indications and contraindications for replantation in the upper extremity.
5. Have a general understanding of reconstructive hand surgery, including congenital hand anomalies, tendon transfers and Dupuytren's contracture.
6. Read:
A. Examination of the Hand, published by the American Society for Surgery of the Hand.
B. The entire text of The Hand: Diagnosis and Indications, by Paul Smith, M.D.
C. Applicable chapters of Green's Operative Hand Surgery textbook before each elective operative case for which the resident is expected to participate.
7. Have a basic understanding of the use of splints for fracture immobilization and tendon rehabilitation.
8. Prepare and present two 45-minute presentations on two different hand surgery topics at the weekly hand service conference during the rotation (over a two-month period).
9. Attend and participate at the weekly hand service conference during the rotation.
10. Attend the orthopaedic residents' journal club that focuses on hand surgery, hosted 2-3 times per year by Drs. Jones, Meals and Benhaim.
11. Attend the biannual lecture series on hand surgery (24 lectures total), presented at the weekly orthopaedic surgery basic science course on Wednesday mornings.
III. Practice-Based Learning and Improvement
1. Frequent, yet focused, use of available printed textbooks (in the orthopaedic library and in Dr. Benhaim's 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.
2. Frequent discussion with hand fellows and attending hand surgeons to present patients after initial evaluation, review available diagnostic tests, and to confirm the appropriate treatment plan. The resident 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.
3. Use of 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.
4. Play an active role in the teaching of junior orthopaedic residents, senior medical students (sub-interns) and junior medical students on the service.
5. 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.
6. Integrate feedback from faculty and hand surgery fellows to ensure that the senior resident 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.
IV. Interpersonal and Communication Skills
1. Demonstrate ability to communicate effectively with all members of the hand service, including medical students, junior residents, hand fellows, and hand surgery attending staff.
2. 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.
3. Demonstrate the ability to interact effectively, professionally, and empathetically with patients and family members.
4. Demonstrate the ability to provide appropriate and detailed information to patients and family members, when appropriate.
5. Demonstrate the ability to develop an appropriate relationship with a patient that fosters communication, respect, and ethics of the highest degree.
6. 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).
7. Demonstrate effective listening and communication skills with patients, which may include both verbal and non-verbal skills.
8. Demonstrate ability to understand and respond appropriately to patient inquiries.
V. Professionalism
1. Demonstrate a strict adherence to medical/ethical principles.
2. 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.
3. 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.
4. Recognize the important social, economic, emotional, and work-related implications that a hand problem or injury may represent for the patient.
5. Provide patients with excellent care in all aspects.
6. Maintain patient confidentiality, including strict adherence to HIPPA guidelines.
7. 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.
8. Demonstrate the ability to accommodate and adapt to differences in patients' culture, age, gender and disabilities.
VI. Systems-Based Practice
1. Develop an awareness of how the care that they provide to patients can affect other caregivers and even the UCLA medical center in general.
2. Demonstrate an ability to effectively utilize hospital resources in a way that directly benefits patient care.
3. Develop a more in-depth understanding of the different types of medical practice available in the context of orthopaedic hand surgery. This will include exposure to care in different settings, such as UCLA private attending clinic, Olive View-UCLA county hospital, Shriners Children's Hospital, West Los Angeles VA Medical Center, and hand surgery clinic run by the hand fellow.
4. 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.
5. 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.
6. 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.).
