Resident Handbook 2021-2022

RESIDENT HANDBOOK 2021-2022 Stanford University School of Medicine Department of Otolaryngology — Head & Neck Surgery

Table of Contents 1.

INTRODUCTION .............................................................................................................................................. 3

2.

STANFORD UNIVERSITY OTOLARYNGOLOGY FACULTY ROSTER ................................................ 4

3.

OTOLARYNGOLOGY RESIDENCY APPLICATION REQUIREMENTS ................................................ 5

4.

RESIDENT ROTATION SCHEDULE ............................................................................................................ 6

5.

POLICY ON RESIDENT PROMOTION ........................................................................................................ 9

6.

POLICY ON RESIDENT DISMISSAL............................................................................................................ 9

7.

360 EVALUATIONS ...................................................................................................................................... 9

8.

POLICY ON SUPERVISION ......................................................................................................................... 10

9.

MENTORSHIP PROGRAM ......................................................................................................................... 10

10. ACADEMIC CURRICULUM ......................................................................................................................... 12 11. DESCRIPTION OF ACADEMIC CONTENT, CONFERENCES AND RESPONSIBILITIES ............. 13 12. RESIDENT TRAVEL AND CONFERENCE FUNDING POLICY............................................................ 16 13. PERSONAL TIME-OFF: ............................................................................................................................... 17 14. RESIDENT WORK HOURS AND CALL .................................................................................................... 18 15. DEPARTMENTAL HAND-OVER POLICY ............................................................................................... 19 16. OPERATIVE CASE LOGS ............................................................................................................................. 20 17. COMMUNICATION ....................................................................................................................................... 20 18. GUIDELINES FOR ONLINE PROFESSIONAL OR PERSONAL ACTIVITY ...................................... 21 19. POLICY AND GUIDELINES FOR INTERACTIONS WITH INDUSTRY ............................................ 21 20. STANFORD DEPARTMENT OF OHNS GUIDELINES FOR CONSULTATIONS ............................. 22 21. OTOLARYNGOLOGY POST-GRADUATE EDUCATIONAL PROGRAM........................................... 24 GOALS AND OBJECTIVES PGY 1 - NON-OHNS ROTATIONS ............................................................................................ 24 STANFORD HEALTH CARE HEADMIRROR SERVICE .......................................................................................................... 30 Goals and Objectives PGY 1: SHC Headmirror Service ..................................................................................... 30 Goals and Objectives PGY 2/3: SHC Headmirror Service ................................................................................ 32 Goals and Objectives PGY 4: SHC Headmirror Service ..................................................................................... 38 STANFORD HEALTH CARE SCALPEL SERVICE .................................................................................................................... 46 Goals and Objectives PGY 1: SHC Scalpel Service............................................................................................... 46 Goals and Objectives PGY 2/3: SHC Scalpel Service .......................................................................................... 47 Goals and Objectives PGY 4: SHC Scalpel Service............................................................................................... 52 Goals and Objectives PGY 5: SHC Scalpel Service............................................................................................... 56 LUCILE PACKARD CHILDREN’S HOSPITAL STANFORD ..................................................................................................... 61 Goals and Objectives PGY 1: PEDIATRIC Otolaryngology ............................................................................. 61 Goals and Objectives PGY 2/3: PEDIATRIC Otolaryngology ........................................................................ 62 Goals and Objectives PGY 4: PEDIATRIC Otolaryngology ............................................................................. 68 VETERAN’S ADMINISTRATION PALO ALTO ........................................................................................................................ 73

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Goals and Objectives PGY 3: VAPA.......................................................................................................................... 76 Goals and Objectives PGY 4/5: VAPA ..................................................................................................................... 81 STANFORD HEALTH CARE: SPECIALTIES TEAM (SCOPE)............................................................................................... 85 Goals and Objectives PGY 1: SHC Specialty Service.......................................................................................... 87 Goals and Objectives PGY 2/3: SHC Specialty Service ..................................................................................... 88 Goals and Objectives PGY 4: SHC Specialty Service.......................................................................................... 97 Goals and Objectives PGY 5: SHC Specialty Service........................................................................................106 SANTA CLARA VALLEY MEDICAL CENTER ...................................................................................................................... 115 Goals and Objectives PGY 2: SCVMC.....................................................................................................................118 Goals and Objectives PGY 5: SCVMC.....................................................................................................................121 STANFORD HEALTH CARE AND LUCILE PACKARD CHILDREN’S HOSPITAL NIGHT FLOAT ROTATION ................ 125 OHNS RESIDENT RESEARCH PROGRAM ......................................................................................................................... 127 22. APPENDICES ..................................................................................................................................................130 APPENDIX A – CONFERENCE DATES .............................................................................................................................. 131 APPENDIX B – KEY INDICATORS..................................................................................................................................... 132 APPENDIX C – HANDOVER EVALUATION FORM ......................................................................................................... 133 APPENDIX D – EVALUATION FORM OF FACULTY BY RESIDENT ............................................................................. 136 APPENDIX E – EVALUATION FORM OF RESIDENT BY FACULTY .............................................................................. 139 APPENDIX F – EVALUATION FORM OF SERVICE/ROTATION BY RESIDENT ........................................................ 142 APPENDIX G – RESIDENT PEER EVALUATION FORM ................................................................................................ 145 APPENDIX H – EVALUATION FORM OF RESIDENT BY STAFF .................................................................................. 148 APPENDIX I – EVALUATION FORM OF RESIDENT BY PATIENT ............................................................................... 150 APPENDIX J – FACIAL TRAUMA CALL POLICY ............................................................................................................. 152 APPENDIX K – MEDICINE/ENT/FACE/ED INTER-SERVICE AGREEMENT........................................................ 154 APPENDIX L – AFTERHOURS OUTPATIENT MEDICAL ADVICE ............................................................................... 156 APPENDIX M – PAGING SYSTEM ..................................................................................................................................... 157 APPENDIX N – VERBAL ORDERS PROCESS CLARIFICATIONS FOR NURSES AND PHYSICIANS ......................... 158 APPENDIX O – TEMPORAL BONE LAB........................................................................................................................... 160 APPENDIX P – SHC INFECTION CONTROL.................................................................................................................... 162 APPENDIX Q – VAPAHCS ENT RESIDENT HANDBOOK 2021-2022 ................................................................ 163

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1. Introduction The Stanford Department of Otolaryngology — Head & Neck Surgery is dedicated to providing the highest level of training to its residents and fellows.

MISSION AND PHILOSOPHY • • • • • • •

Provide patient care with both expertise and compassion Foster dedication to life-long learning and teaching Excel at state-of-the art medical care for patients with otolaryngological diseases Take an investigative approach to the scientific and policy questions in medicine Invent new approaches to diagnosis and therapy Implement and optimize emerging technologies Be active world citizens in the provision of health care to those most in need

This handbook describes policies and procedures associated with the Otolaryngology/ Head & Neck Surgery residency, as well as the expectations for successful completion of the program. It is updated annually.

The Graduate Medical Education Office’s House Staff Handbook is available for download at: https://med.stanford.edu/gme/policy.html

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2. Stanford University Otolaryngology Faculty Roster Department Chair

Stanford Konstantina M. Stankovic, M.D., Ph.D.

Vice Chair Residency Program Director Associate Program Director

Peter Hwang, M.D. C. Kwang Sung, M.D., M.S. Jennifer Alyono, M.D., M.S. Iram Ahmad, M.D., M.M.E. Fred Baik, MD Karthik Balakrishnan, M.D., MPH Nikolas H. Blevins, M.D. Robson Capasso, M.D. Kay W. Chang, M.D. Alan Cheng, M.D. Edward J. Damrose, M.D. Karuna Dewan, M.D. Elizabeth DiRenzo, Ph.D. Vasu Divi, M.D. Matthew Fitzgerald, Ph.D. Nicolas Grillet, Ph.D. Stefan Heller, Ph.D. Floyd Christopher Holsinger, M.D. Peter H. Hwang, M.D. Robert K. Jackler, M.D. Michael J. Kaplan, M.D. Peter J. Koltai, M.D. Jennifer Lee, M.D. Stanley Liu, M.D., D.D.S. Dáibhid Ó Maoiléidigh, Ph.D., M.S. Kara Meister, M.D. Uchechukwu Megwalu, M.D., MPH Lloyd Minor, M.D. Sam P. Most, M.D. Jayakar Nayak, M.D., Ph.D. Teresa Nicolson, Ph.D. Julia Noel, M.D. Lisa Orloff, M.D. Zara Patel, M.D. Jon-Paul Pepper, M.D. Robert Riley, M.D., D.D.S Eben Rosenthal, M.D. Anthony Ricci, PhD Peter Santa Maria, MBBS, Ph.D. John Shinn, M.D. George Shorago, M.D. Doug Sidell, M.D. Davud Sirjani, M.D. Heather Starmer, M.A. Kristen Steenerson, M.D John Sunwoo, M.D. Mai Thy Truong, M.D. Tulio Valdez, M.D., MSc 4

Fellows & Clinical Instructors Pediatrics – Brooke Su-Velez, M.D., MPH & Taseer Din, MBChB Facial Plastic – Sarah Akkina, M.D., MSCR Laryngology – Idris Samad, MBBCh Rhinology – Michael Chang, M.D. & Christopher Low, M.D. Sleep – Thomaz Fleury Curado, M.D., Ph.D. & Allen Huang, M.D., D.D.S. Head & Neck – Andrey Finegersh, M.D., Ph.D. & Kyle Hannabass, M.D. Otology – Adam Kaufman, M.D. & Lindsay Moore, M.D. Affiliated Faculty

Santa Clara Valley Medical Center M. Lauren Lalakea, M.D. (Section chief) Kimberly Shepard, M.D. Micah Saste, M.D. Amanda Muñoz, M.D. Misha Amoils, M.D. Veterans Administration Palo Alto Davud Sirjani, M.D. (Chief) Sarah Akkina, M.D., MSCR Jayakar Nayak, M.D., Ph.D. Bohdan Makarewycz, M.D. Hamed Sajjadi, M.D. C. Kwang Sung, M.D., M.S.

3. Otolaryngology Residency Application Requirements •

The Stanford Department of Otolaryngology — Head & Neck Surgery welcomes qualified applicants for consideration for appointment to its ACGME-accredited residency program. Please see the “Resident eligibility – recruitment” section of the Stanford House Staff Policies & Procedures for details of eligibility. The department encourages residency applications from all qualified individuals regardless of age, sex, ethnic background, religious beliefs, or sexual orientation with an interest and a proven track record of excellence in scholarly pursuits.

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Stanford participates in the Electronic Residency Application Service (ERAS) for otolaryngology. Rank lists are submitted by both the program and the resident applicants, and a matching algorithm is applied.

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All applications received by Stanford are individually reviewed. Candidates are selected for interviews based on this initial review. Once interviews are conducted, decisions about candidate selection are made by consensus among the faculty.

Approximately 45 invitations for interviews are offered from among more than 300 applications. Interviews take place on two days in January.

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4. Resident Rotation Schedule

Key: Scalpel: Scope: HM: Peds: NF: SCVMC: VA: MF: Elective:

Head and Neck Surgery Specialties (Otology, Rhinology, Facial Plastic Surgery) Headmirror (Laryngology, Sleep Surgery, Comprehensive Otolaryngology) Pediatric Otolaryngology Night Float Otolaryngology department at Santa Clara Valley Medical Center Otolaryngology department at Veterans Affairs Palo Alto Health Care System Mini Fellowship Options for rotating on sub-specialties, or extra-departmental rotation

Rad/Res: Anes*: ED*: Plastics*: SICU*

Radiology (neuroradiology) / Research Anesthesia, Stanford Health Care Emergency Department, Stanford Health Care Plastic Surgery, Stanford Health Care Stanford Health Care Intensive Care Unit

SCV GS*:

General Surgery, Santa Clara Valley Medical Center

VA GS*:

General Surgery, Veterans Administration Palo Alto * PGY1 rotations with General Surgery Department

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5. Policy on Resident Promotion Stanford is fortunate to attract the highest caliber of residents in the nation. It is expected that each resident has the necessary skills and intellect to be promoted through the residency and graduate successfully. Prior to completion of the program, otolaryngology residents are expected to demonstrate competence in patient care, medical knowledge, professionalism, system-based practice, practice-based learning and improvement, and interpersonal and communication skills.

They are likewise expected to complete and excel in the research requirements of the program.

Twice a year, the program director conducts a meeting with each resident to discuss resident performance and educational development. At these meetings, evaluations of the resident (that have been completed by the resident, faculty, nurses/adjunct personnel, and patients) are discussed at length. Attendance record at conferences, resident research projects, operative logs, and planned/completed portfolio projects will be reviewed.

6. Policy on Resident Dismissal Residents are expected to satisfy at least a minimum level of competence in order to be promoted.

Residents failing to achieve the minimal level of competence as determined by the evaluations will be given written notice of that fact. Depending on the nature of the deficiency, they may then be placed on probation. This period of probation will last at least three months and will be accompanied by a detailed plan to address any deficiencies in the resident’s performance.

Residents who are on probation for a minimum of three months and who have not successfully improved their performance to meet at least the minimal level of competence may be dismissed.

7. 360 Evaluations Performance evaluations are completed by various members of the healthcare team including faculty, staff (nurses, MAs, physicians’ assistants, nurse practitioners, technicians, anesthesiologists, etc), patients and peers. These evaluations address performance in the core competencies and are sent to evaluators after every rotation, including the research block.

Evaluations are conducted on-line via the MedHub system to assure anonymity. In an effort to obtain a 360-degree evaluation, patients are also randomly asked to compete evaluations based on their interactions with residents.

Peer evaluations are held from resident-access until the end of the year to protect anonymity.

However, at the semi-annual review meeting, the program director will share aggregated feedback of these evaluations verbally. Resident(s) with the highest peer ratings for outstanding teaching will be awarded the “Resident Teacher of the Year” award at the end of the year. An award will also be given for the resident rated highest as an outstanding team player by their peers.

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Meaningful evaluation of the faculty and the program is a critical aspect of the residency program; it is a tool for improving educational quality and the resident learning environment.

Residents are therefore expected to complete faculty and rotation evaluations in a timely fashion after the end of each rotation.

Residents will have access to their evaluations by faculty upon completion of their faculty/rotation evaluations. To assure anonymity, the evaluations of faculty and rotations will not be collated or made available to faculty until the end of the academic year. Evaluations by residents are always anonymous.

8. Policy on Supervision See GME handbook for policies.

Stanford OHNS System Triggers for Attending Communication • • • • • • • • • • • • • •

Admission/discharge Transfer in/out of ICU Unplanned intubation Cardiac arrest or hemodynamic instability Neurological changes Wound complications Any medication or therapeutic error that leads to a change in patient management Unplanned transfusion Any clinical problem requiring an invasive procedure ER visit Any concern by a trainee that a situation is more complicated than he or she can manage Any request that an attending surgeon be contacted Any situation in which a parent requests attending notification or feels that an issue has not been adequately resolved or addressed Any new onset/worsening of symptoms out of proportion to expectations

9. Mentorship Program Beginning July 2020, the faculty mentoring program has been restructured. Rather than 1:1 faculty to resident pairings, residents are now assigned to cohorts of five to six residents representing each post-graduate year, and these cohorts are assigned to one faculty member.

The cohorts will meet at least three times a year for activities (eg dinner, outings) with their mentors.

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The goals of this program are to encourage more routine interactions, develop closer group dynamics and friendships, and foster supportive social and professional networks.

The resident may consult the faculty mentor as needed on any issues either professional or personal. The resident should also feel free to consult the Program Director regarding any such subjects.

The faculty mentors will function as liaisons to the rest of the faculty for issues regarding resident academic, clinical and operative performance as well as well-being.

Group 1

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3

4

5

# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Resident Losorelli Wei Munjal Soo Ayoub Kiessling Fullerton Coughran Cohen Kligerman Ezzibdeh Rahman Huang Howard Domville-Lewis Kashani Park Azimzadeh Lee Okland Kim Belsky Diop Liu Oliveira Qian Vukkadala

PGY 1 2 3 3 4 1 2 3 4 5 1 1 2 3 4 5 2 2 3 5 5 1 2 3 4 4 5

Track CT CT T32 T32 CT T32 CT CT CT CT CT CT CT CT CT CT T32 CT T32 CT T32 CT CT CT CT T32 CT

Mentor Orloff

Sunwoo

Patel

Divi

Hwang

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Resident Mentors The otolaryngology peer-mentoring program was started in 2009 to provide a formalized career and personal support system to junior residents. Incoming interns are paired with mid-level residents, based on consideration of their common interests. Senior residents have an opportunity to offer professional guidance, moral support, process decisions and the like.

Notifications of these pairings are made in the spring prior to incoming interns’ arrival to Stanford.

Class beginning 2020 Mohamed Diop – Flavio Oliveira Zoë Fullerton – Samuel Cohen Alice Huang – Chloe Domville-Lewis Eric Wei – Noel Ayoub Ki Wan Park – Yu-Jin Lee Class beginning 2021 Michael Belsky – Javier Howard Rami Ezzibdeh – Joanne Soo Patrick Kiessling – Julien Azimzadeh Steven Losorelli – George Liu Arifeen Rahman – Alanna Coughran

10. Academic Curriculum Required Assignments The following is a list of the principle required projects and talks during the course of the residency: All five years of residency ❑ Otolaryngology In-training Exam ❑ Temporal bone lab PGY1 ❑ Radiology case presentation assembled during Radiology/Research Rotation PGY2 ❑ Research proposal, due at semi-annual meeting with program director in January/February. ❑ Residency Research Symposium Presentation ❑ Radiology case presentation for Resident Education PGY3 ❑ Residency Research Symposium Presentation ❑ Abstract submission to the Bay Area Residency Research Symposium

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❑ Quality Improvement Project PGY4 ❑ Residency Research Symposium Presentation PGY5 ❑ Grand Rounds ❑ Residency Research Symposium Presentation

11. Description of Academic Content, Conferences and Responsibilities Residents are responsible for core learning as outlined in the following document: http://www.aboto.org/pub/Core%20Curriculum.pdf The academic curriculum is based on a rotating two-year cycle so that each resident is exposed to each topic at least twice during his/her residency. Weekly Residency Education conferences are held on Mondays 8:00-9:00 AM. Residents are expected to be on time for 80% of sessions (except for cases of pre-approved excused absences). Residents at SCVMC and VAPA will be expected to participate via Zoom videoconference. Attendance records will be tracked, and will be reviewed by residents and faculty.

The Thursday evening conferences (Grand Rounds and Quality Improvement) begin at 6:00 PM. In addition, there will be at least one book club, and journal clubs are held on weekday evenings (usually on Mondays) four times a year. Residents will be assigned to help organize the journal clubs. Residents are expected to practice drilling in the temporal bone lab on their own to meet required competencies. See appendix (Temporal Bone Lab) for more information. The Quality Improvement Project, whose curriculum has been redesigned, will be a requirement of all residents in their PG3 year.

The use of laptops is not permitted during Grand Rounds.

The PGY5 chief residents will be assigned to give one grand rounds session during the year.

All residents rotating at Stanford and LPCH are expected to attend Monday morning conference from 7:15-8:00 AM. The course subjects include Neurotology Radiology, Laryngology, Rhinology, Trauma, Sleep Surgery, and Pediatric Otolaryngology conference. The residents rotating at SCVMC and VAPA are expected to participate in the Monday morning conferences via Zoom videoconference.

All residents on the Scalpel Service are required to attend the Head & Neck Resident Case Conference every Thursday 4:00-4:30 PM, followed by Head & Neck Tumor Board 4:30-5:00 PM. All residents are required to complete an allergy course either online or in person at some point during their residency. In addition, all residents must spend a minimum of two half-days in the Allergy Clinic to gain hands-on experience with skin testing. Contact Dr. Meng Chen at mengchen@stanford.edu at least one month in advance to schedule your clinic time. These 13

requirements can be completed in any PGY year. Due to travel restrictions this year, the requirements may be completed online through the World Allergy Organization website: https://www.pathlms.com/wao/ The following allergy sessions should be completed: https://www.pathlms.com/wao/courses/585 https://www.pathlms.com/wao/courses/4114 https://www.pathlms.com/wao/courses/1771 https://www.pathlms.com/wao/courses/572 https://www.pathlms.com/wao/courses/586 https://www.pathlms.com/wao/courses/576 https://www.pathlms.com/wao/courses/581 All residents are required to take the in-training exam each year of residency, held the first Saturday of each March, with the exception of residents in their dedicated research years of the T32 track.

Attendance Policy Conferences Attendance will be taken at each of the Monday conferences at 8:00 AM and other required conferences (eg journal club, grand rounds, etc) and other events (residency meetings, symposium, etc).

Mandatory Events Residents are required to be present for the following annual events. Vacation time should be scheduled accordingly: • • • •

Residency graduation Residency Research Symposium In-training exam (first Saturday of March) Residency Annual Program Evaluation/Retreat (usually the first Monday in June)

Annual In-training Exam All residents, including the PGY1 residents with the exception of residents in their dedicated research years of the T32 track, are required to sit for the in-training exam, administered the first Saturday of March. Residents who achieve scores in the 7th-9th group stanines will receive prizes of $500 for academic purposes. Those in the bottom three stanines will be required to submit a written study plan to the program director and their assigned mentor, and to meet with their mentor on a quarterly basis to discuss progress.

Residency Research Symposium Every year, on graduation Friday, the department hosts a day-long symposium to showcase research conducted by residents over the year. Maximum time for the presentation is 7 minutes (with an additional three minutes of question and answer time). Presentations are judged by selected faculty and the guest of honor using a criterion-based rubric, which is provided to the residents in advance. PGY2-5 are required to give a presentation. A grand prize of $500 in

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academic funds is given to the best overall presenter; there are two runners up, receiving $250 in academic funds each in the categories of presentation and content, respectively.

To be eligible for these prizes, the material presented must constitute original research conducted by the resident (which has also not been previously presented in years past, but may have been presented at a national conference or the Bay Area Residency Research Symposium). An abstract of the talk is due two weeks before the symposium date.

Quality Improvement (QI) Curriculum Effective July 1, 2020, the QI curriculum has been revamped. While its purpose remains the same, this learning requirement has been restructured, is now being overseen by Dr. Karthik Balakrishnan, and is a collective rather than individual resident project of PGY3’s.

The aim of the QI project is to develop a plan to support a hospital or clinical performance improvement or patient safety measure by: • • • •

Reflecting on practice and practice analysis Critically analyzing the current literature Developing a plan for implementation of the proposed change Developing an outcomes’ assessment (performance measure)

Its overall purpose is to foster an understanding of the complexities of health care delivery and develop the skills to address them as is described by the core competency, Systems-Based Practice.

The program is illustrated in the image below. Working sessions will take place on weekday evening, four times a year between July and October. Thereafter the team will meet on its own for completion of the project in the following June.

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National Academic Conferences Every attempt will be made to relieve the PGY2 or PGY3 residents from their clinical duties so that they may attend the Combined Otolaryngology Spring Meeting sponsored by the Department one time.

In addition, all residents who have abstracts accepted for podium presentation at a regional or national meeting will be relieved of their clinical responsibilities in order to attend the meeting and present their data. PGY1-3’s who have abstracts accepted for poster presentation at a regional or national meeting will be relieved of their clinical responsibilities, if possible, in order to attend the meeting. They will be eligible to receive funding to offset the costs of the meeting (currently set at a maximum of $1,400 per conference). There is no maximum on the number of conferences a resident may attend. See Policy on Resident Travel.

Fellowship Interviews Many otolaryngology residents pursue fellowships in otolaryngology subspecialties after their residency. The faculty recognizes that residents need to interview for these fellowships and will make every effort to release residents from their clinical duties so that they may attend these interviews. Fellowship applicants are asked to try to minimize the days away from their rotation as their absence places an undue burden on their fellow residents.

12. Resident Travel and Conference Funding Policy Note: Check the latest updates on University-sponsored travel.

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Resident travel to the following scientific meetings will generally be approved for departmental support: American Association for Research in Otolaryngology (ARO), Combined Otolaryngological Spring Meetings (COSM), American Academy of Otolaryngology-Head & Neck Surgery Annual Meeting (AAO-HNS), and Section Meetings of the Triological Society.

Travel to other meetings may be approved on a case-by-case basis by the program director.

In addition, funding approval will require that the following three circumstances exist: The resident must be the podium speaker, course lecturer, or poster presenter. Poster presentations are generally acceptable only for PGY1-3 residents (at the time of the presentation). If a poster of a PGY4-PGY5 resident is accepted the resident may be eligible for travel funding but this must be approved by the program director ahead of time. However, posters on laboratory basic science topics are acceptable at any training level.

In addition, the work must be original and presented for the first time and, the presentation must be accompanied by a manuscript that is submitted to a peer reviewed journal before the time of the meeting.

Expense Guidelines (pending update on moving all travel booking to Stanford Travel Program): ▪ Roundtrip airfare will be reimbursed at the lowest available fare.

▪ Meeting registration reimbursement will be based on early pre-registration, not at-thedoor fees.

▪ Hotel lodging costs should be reasonable and follow university’s Hotel Lodging Rate Guidance: https://web.stanford.edu/group/fms/fingate/staff/travel/policy_notes/lodging.html ▪ Meals will not be reimbursed.

▪ Total departmental reimbursement for a given meeting will be a maximum of $1,400 per domestic trip.

▪ Poster expenses are reimbursed up to $100. This is considered separate from the travel expenses.

NOTE: The ultimate approval of all resident travel at departmental expense is at the discretion of the program director and departmental chair. Approval of reimbursement for travel not meeting the above criteria may be possible under certain circumstances and will be evaluated on a caseby-case basis.

13. Personal Time-off: House staff are permitted to take up to three weeks of personal time off with pay during each one-year period. Vacation should be scheduled in 1-week blocks unless prior approval is obtained from the program director and the rotation director (for example if 2 weeks are requested together or if a partial week is requested). Personal time off must be requested and subsequently approved through the MedHub system. Stanford University Medical Center believes that personal time away from the residency program is important to the welfare of house staff, so unused personal time off does not accumulate from year to year and there is no provision to pay in lieu of time off.

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Residents should not plan on taking vacation at the time of the in-training exam, during the time of the Annual Program Evaluation (Residency Retreat), or during the week of the chief residents’ graduation dinner and the annual Resident Research Symposium. At a minimum, rotation directors and the PD should be notified no less than 2 weeks before the rotation starts. All time off must be recorded in MedHub. So-called “terminal leave,” vacation as the final week of residency, will be considered on an individual basis for residents who will be pursuing a fellowship. A resident who is taking terminal leave should not take an additional week of vacation during the same rotation block.

Time off for fellowship/job interviews Residents are not permitted to take vacation in any quarter in which they will be gone for more than five days due to interviews. Residents must report the number of days they will be taking off to the program director. To avoid patient care coverage issues, PGY2’s should try not take vacation when a resident on the same rotation is interviewing.

14. Resident Work Hours and Call The Department of Otolaryngology — Head & Neck Surgery is committed to following the current ACGME policies on duty hours. See GME handbook for policy.

The resident call schedule will be determined by the chief residents. First call is shared among junior and senior residents; the second call is by the chief resident, or in the event of the chief resident’s absence, by the most senior resident on the service. Third call is staffed by a faculty member. Recognizing the individual resident circumstances and needs and acknowledging the autonomy of the specific sites within the residency program, it is understood that the residents will be allowed to determine their own call schedule, to the extent that this does not create any undue hardship for any individual resident and it follows the above guidelines. As much as possible, no resident should be on call 2 weekends in a row. Resident work hours are monitored on a weekly basis and any potential issues are addressed immediately.

The following guidelines were adopted for the 2020-2021 Academic Year to address duty hour concerns: All Residents: • All day residents should leave the hospital by 9 pm weekdays. May voluntarily elect to stay (if working within 80 hours, 1 in 7 days off guidelines): – to continue to provide care to a single severely ill or unstable patient – humanistic attention to the needs of a patient or family – to attend unique educational events • The night float resident should actively take over day residents’ work (e.g., in the OR) to allow them to leave by 9 pm, if there are no active consults.

• Attending or fellow to dictate cases when finishing after 9 pm.

Junior Residents • Night float resident will work every other Friday night.

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Chiefs may allow junior residents on call for the weekend (PGY 2–4) to skip morning rounds during the week.

– These residents should also leave the hospital each day as soon as their clinical responsibilities are completed.

Peds Weekend Rounds: The post-call resident rounding must leave the hospital by 10 am.

– The SHC junior resident or chief should take over any remaining work to allow for the resident to leave on time.

Attending on weekend call must round no later than 8am.

Interns • SHC intern on for the weekend can work a maximum of 14.5 hours/weekday and 7 hours/weekend day (6am – 1 pm) (86.5 hours total).

• LPCH intern can work a maximum of 14.5 hours/weekday and 7 hours on Saturday (6am - 1pm) (79.5 hours total).

– LPCH intern is on every Saturday during the rotation.

• Chiefs should ensure these hours are adhered to by scheduling clinical responsibilities accordingly and releasing interns by 7:30pm even if PM rounds have not been completed.

Valley/VA Night and Weekend Call • Full-time research residents will take 1 weekend of call per month. They may also take up to 1 weeknight call on the other weeks.

• PGY4s on research time may take 1 weeknight call per week – When there are no full-time research residents, the PGY4 on elective time will follow the call schedule for full-time research residents.

• Frequency of weeknight call for research residents may vary depending on the number of residents on research at one time.

On-call rooms are provided.

All residents are required to enter their work hours into the MedHub system on at least a weekly basis.

15. Departmental Hand-over Policy When on-call, residents typically cover patients at more than one hospital. For this reason, a verbal check-out procedure via phone is currently used by the resident staff. Elements of this policy include: Prior to leaving the hospital each day: • Junior residents check-out to on-call junior resident or to night float resident every patient via I-PASS (I: Illness severity; P: Patient summary; A: Action items; S: Situation awareness and contingency planning; S: Synthesis by receiver).

• After checking out, the Junior resident(s) with the ghost consult and floor pagers will reassign the pagers to the on-call resident. In the morning the resident assuming the

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consult pager will reassign the ghost pager, and each resident covering the floor ghost pagers will reassign the pagers.

Senior/chief residents check out to senior/chief residents regarding all unstable/concerning patients.

Faculty members check out all concerning patients to faculty member on call.

16. Operative Case Logs All residents are required to enter data on their surgical cases into the ACGME system in a timely manner (every week recommended, operative logs must be up-to-date at the time of the semi-annual resident meeting with the program director.)

Residents are responsible for keeping track of the surgical cases in which they participate.

A Resident Supervisor instructs, and assists as needed, a more junior resident during a procedure during which the junior resident performs greater than or equal to 50% of the operation, including the key portion(s) of the procedure. The attending functions as an assistant or observer.

A Resident Surgeon performs greater than or equal to 50% of the operation with the attending surgeon (and resident supervisor, if applicable), including the key portion(s) of the procedure.

An Assistant Surgeon performs less than 50% of the operation, or greater than or equal to 50% of the operation but not the key portions(s) of the procedure.

Residents are responsible for entering all data into the ACGME database. Accuracy in this endeavor is critical, both for justifying a resident’s suitability for sitting for the board examination, as well as accurately reflecting the volume of surgery done in the program.

The required minimum number of key indicator procedures is listed in Appendix D. Coding guidelines are listed at: https://medwiki.stanford.edu/display/ent/Protocols+and+Forms

17. Communication Addresses: The resident home addresses, email addresses, home phone numbers and cell phone numbers should be provided to the administrative staff within the department and updated on Medhub.

E-mail: Residents are required to maintain an active Stanford e-mail address that is checked regularly (at least every 48 hours). All clinical and academic e-mail should be sent through this system. All e-mail with personal health information (PHI) must be sent securely (this is done by typing “SECURE:” at the beginning of the e-mail subject line).

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18. Guidelines for Online Professional or Personal Activity These guidelines apply to Stanford OHNS residents in social medical venues such as professional society blogs, LinkedIn, Google+, Instagram, and/or Facebook, for deliberate professional engagement or casual conversation.

• • • •

Protected Health Information, including photographs, may not be placed on social media sites.

For the purposes of education, descriptions of patient cases and clinical images may be posted to password protected professional sites once the data has been de-identified.

By virtue of identifying oneself as a part of Stanford in social media, residents connect themselves to, and reflect upon, Stanford colleagues, Stanford patients and supporters.

Remember that all content contributed on all platforms becomes immediately searchable and can be shared. This content leaves the contributing individual’s control forever.

19. Policy and Guidelines for Interactions with Industry The above policy may be accessed at: https://med.stanford.edu/siip/home.html Highlights of this policy include: 1) Medical staff, faculty, students, and trainees may not accept gifts from Industry anywhere at the Stanford SOM, SHC, LPCH, or other clinical facilities operated by either hospital. It is strongly advised that no form of personal gift from Industry be accepted under any circumstances.

2) Free drug samples given directly to members of the SUMC are considered gifts and may not be accepted, except by the pharmacy for use for needy patients.

3) Gifts or compensation may not be accepted a) at any Stanford or non-Stanford facility such as other hospitals and outreach clinics, b) for listening to a sales talk by an industry representative, c) for prescribing or changing a patient’s prescription, d) for simply attending a CME or other activity or conference, including the defraying of costs.

4) Meals or other types of food directly funded by Industry may not be provided at Stanford SOM, SHC, LPCH, or Menlo Clinic.

5) Sales and marketing representatives are not permitted in any patient care areas except to provide in-service training on devices and other equipment and then only by appointment.

They are permitted in non-patient care areas by appointment only.

6) Industry support of students and trainees in the SOM educational programs should be free of any actual or perceived conflict of interest, must be specifically for the purpose of education and must comply with several provisions: a) The Department selects the student or trainee, b) The funds are provided to the School, department, program, division, or institute and not directly to the student or trainee or to an individual faculty member; c) The department, program, division, or institute has determined that the funded conference or program has educational merit, d) the recipient is not subject to any implicit or explicit expectation of providing something in return for the support.

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SOM faculty, students, staff and trainees should evaluate carefully their attendance at meetings and conferences that are fully or partially sponsored or run by Industry because of the potential for perceived or real conflict of interest.

20. Stanford Department of OHNS Guidelines for Consultations General guidelines for all consults: ◼ Otolaryngology is a service oriented specialty where relationships with practitioners of other services are established and maintained. ◼ ALL consults should be seen the day they are received unless it is late in the day and the referring provider expressly states that it is fine to see the next day. If the consult is received but not seen on that day, please see the consult yourself on the following day so another resident is not left with your work. ◼ If a consult is received and you think it is truly an inappropriate consult the OHNS Chief resident MUST hear about the consult and give permission for the OHNS resident to not see the consult. ◼ Consults take priority over the OR. ◼ All consults must be staffed with the on call attending the day of the consult. ◼ A consult note must be entered on the day of the consult (including vocal fold consults).

This includes any consult you see, even ones that are immediately signed off on. ◼ A full consult note must be entered for every consult patient. It is not OK to only enter a procedure note without a consult note (for example: a full consult note needs to be entered for a patient with possible vocal fold paralysis – not just the laryngoscopy note.) ◼ During the day, the consult note may (and should) be started but not completed (i.e. don’t put the assessment and plan) until the consult has been seen/discussed with the attending. ◼ All outpatient calls should be returned in a timely fashion and have a telephone encounter documented in the appropriate EPIC. ◼ The night float residents should see and document all consults- even ones that are not urgent. ◼ Referring providers should be treated with respect – just as we want to be treated when we call in a consult. Inevitably, we will receive some consults for conditions we think are “silly” or “a waste of time”. Remember that we sometimes call in these types of consults too. A consult is a request for help. BE NICE. Emergency Department Consultations: ◼ Should be seen within 1 hour of receiving the call (obviously quicker for urgent consults) ◼ Always check out with the ED physician- don’t leave without talking to them.

Consults at SCH: ◼ The Consult PGY 2 (and occasionally 1) serves as the front line consult resident. ◼ Consults will be added to the team of the staffing attending (ie a consult staffed by a Scope attending will go to the Scope service.) ◼ Trach consults will go to the service of the staffing attending. ◼ Vocal fold consults go to the Headmirror service.

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◼ Existing H&N patients with a H&N issue will go to Scalpel even if not yet staffed with the H&N attending (i.e. laryngeal tumor patient followed by Kaplan in the past but staffed with rhinology fellow will go to H&N) ◼ New H&N patients will go to team of staffing attending unless directed otherwise by the chief (i.e. new tongue SCC consult staffed by FPRS fellow will go to Scope at first.) ◼ If you want a consult to be seen in a fellow/instructor clinic (i.e. mandible fracture to be seen in FPRS clinic) you must email, call or text that attending. A STAFF MESSAGE ALONE IS NOT SUFFICIENT! Consults at LPCH: Please refer to Peds Service Guidelines provided by the division.

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21. Otolaryngology Post-Graduate Educational Program Goals and Objectives PGY 1 - Non-OHNS rotations Rotation Contacts and Scheduling Details Rotation Director: Kwang Sung, MD, MS kwangs@stanford.edu NOTE: All residents, including the PGY1 residents, will take the in-training exam on the first Saturday in March.

Rotation details: The daily schedules will be determined by the chief residents/faculty on each individual rotation.

While on other rotations residents should attend the resident education sessions for that specialty. Residents should attend the OHNS education sessions when feasible.

Radiology/Research Rotation This rotation is comprised of neuroradiology, audiology, neurology and research.

Rotation Contacts & Addresses Rotation Directors: Nancy Fischbein, MD nancyfb@stanford.edu Matt Fitzgerald, PhD fitzmb@stanford.edu Clinics:

Besides Stanford and LPCH, the locations for this rotation include: • • • •

451 Sherman Ave Hoover Pavilion (SNHC, Stanford Neurosciences Health Center, 213 Quarry Rd) VAPA Stanford Ear Institute (Watson Court)

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Rotation Details: • One week before the rotation, resident is to touch base with Dr. Fischbein (Fischbein@stanford.edu; 650-387-1853) and/or Dr. Mrudula Penta (mrudula@stanford.edu). Ask them for upcoming faculty/fellow schedules and conference schedule.

• At least one week before the rotation, resident is to make an appointment with Drs. Kara Meister (meister4@stanford.edu) or Iram Ahmad (ahmadin@stanford.edu), residency research committee faculty, to discuss research goals.

• At least two half-days are to be spent in neurology clinic shadowing Dr. Kristen Steenerson (on Mondays, Tuesdays, Thursdays or Fridays). Please contact Dr. Steenerson (ksteen@stanford.edu) one month in advance to arrange.

• Residents will attend OHNS conferences on Monday mornings and neuroradiology conferences (see list) as appropriate and as possible. The mornings will generally be spent in the neuroradiology reading rooms at Stanford, LPCH, Sherman Ave and/or Hoover.

• One afternoon (Wednesday or Friday) a week will be spent in audiology, primarily at the Stanford Ear Institute at Watson Court.

• Afternoons not spent in audiology or neurology are to be utilized to develop research plans.

Residents are required to complete the project specified in the G&Os. Conferences: In addition to attending Monday morning and Thursday afternoon OHNS conferences, the resident is encouraged to attend the following conferences, depending on appropriateness of content. Current schedules may be accessed online at: http://med.stanford.edu/neuroimaging/education/intranet.html Conference

Time

Locations

Mondays – Neuroradiology Fellows Conference

1:30 PM

Alway M015A (basement of Always building) or by Zoom off-site

Tuesdays – Neuroradiology Fellows Conference

7:30 AM

Alway M015A (basement of Always building) or by Zoom off-site

Tuesdays – Neurosurgery Skull Base Conference

5:30 PM

CC2103 except every third Tuesday, when it is at Blake Wilbur 1084.

Wednesday – Third Wed of month (usually): Peds ENT Radiology Conference

5-6pm

LPCH Conference Room

Thursdays – Radiology Resident didactic block

Noon-5pm (if Neuro lectures, typically at 12:30 and 1:30 p.m.)

Glazer Learning Center (Lucas Building)

Thursdays – Head & Neck Tumor Board

4:30-6:30 PM

CC2103 25

Resources: • • •

Diagnostic Imaging: Head & Neck, 3rd Edition by Koch, et al Expert Differential Diagnoses: Head & Neck, by Harnsberger AJNR (Am J Neuroradiol) Special Collections: -link to H+N papers: http://www.ajnr.org/site/specCol/SpecColl7TOC.xhtml -note: a bound copy can be ordered for $50 if one wants to

Competency-based Goals and Objectives General & Plastic Surgery rotations: To be able to provide pre-and postoperative care to the surgical patient.

Resident Objectives: ACGME Competency Goals ▪ Be able to take a detailed surgical history and review relevant medical records.

Patient Care Interpersonal and Communications Skills ▪ Be able to perform a detailed physical examination.

Patient Care Medical Knowledge ▪ Be able to write/dictate a thorough and succinct history & physical.

Patient Care Interpersonal and Communications Skills ▪ Understand the process of obtaining a surgical informed consent.

Patient Care Systems-Based Practice ▪ Be able to complete a thorough clinical note in the inpatient record.

Interpersonal and Communications Skills Patient Care ▪ Understand NPO guidelines.

Medical Knowledge Patient Care ▪ Understand fluid management in the NPO patient.

Medical Knowledge Patient Care ▪ Understand the basic laboratory and radiologic tests performed for the pre-operative and postMedical Knowledge operative patient.

Patient Care ▪ Understand the basics of nutritional support for the surgical patient.

Medical Knowledge Patient Care ▪ Understand operative sterility principles.

Medical Knowledge Patient Care ▪ Understand the diagnosis and basics of management of surgical related infections.

Medical Knowledge Patient Care 26

▪ Understand the guidelines and use of prophylactic antibiotics.

Medical Knowledge Patient Care ▪ Learn how to effectively utilize the “EPIC” computerized medical record.

Systems-Based Practice Goal for Surgical Intensive Care Unit rotation: To understand the basics of care for the critically ill surgical patient.

Resident Objectives: ACGME Competency Goals ▪ Understand the different types of shock.

Medical Knowledge ▪ Understand the various types of monitoring catheters and how to interpret the data obtained

Medical Knowledge

▪ Understand the basic principles of mechanical ventilation.

Medical Knowledge

▪ Understand effective preventive measures for deep vein thrombosis and pulmonary embolus.

Medical Knowledge Patient Care ▪ Understand the basics of EKG interpretation Medical Knowledge ▪ Understand the basics of renal physiology and electrolyte disturbances.

Medical Knowledge ▪ Understand the basics of pulmonary physiology Medical Knowledge ▪ Be able to manage the nutritional needs of the surgical patient.

Patient Care ▪ Learn about optimal communication between the intensivists and surgical teams.

Professionalism Systems-Based Practice Goals of Emergency Medicine rotation: To understand the basics of care in the emergency department.

Resident Objectives: ▪ Learn about the process of E.D. triage.

▪ Know how to evaluate the most common disorders seen in E.D. patients.

▪ Learn how to work with the E.D. personnel and other medical professionals to evaluate and treat patients.

▪ Learn the basics of laceration closure.

ACGME Competency Goals Medical Knowledge Patient Care Systems-Based Practice Medical Knowledge Patient Care Medical Knowledge Patient Care Systems-Based Practice Patient Care Medical Knowledge

Goals for Anesthesia Rotation: To become familiar with the basics of anesthesia care.

Resident Objectives: ▪ Know basic laryngeal anatomy.

ACGME Competency Goals Medical Knowledge 27

▪ Know appropriate indications for general versus local versus regional anesthesia.

▪ Know the important features of the most common surgical anesthetics used in the operating room.

▪ Understand appropriate preoperative tests for patients undergoing anesthesia.

Medical Knowledge Patient Care Patient Care Medical Knowledge

▪ Be able to interpret the anesthesia record.

Medical Knowledge Patient Care Medical Knowledge

▪ Be familiar with various types of intraoperative monitoring.

Medical Knowledge

▪ Be able to perform orotracheal intubation.

Patient Care Patient Care

▪ Learn about optional communication between anesthesia and surgical teams.

Patient Care Professionalism Systems-Based Practice ▪ Learn how to participate in a “time out” session and understand the importance of surgical Patient Care checklists.

Systems-Based Practice Goals of Neuroradiology/Audiology/Neurology/Research rotation: To become facile at ordering and reading imaging studies of the head and neck, to understand the basics of audiology and vestibular testing, become familiar with basic neurological assessments, and learn the fundamentals of conducting medical research.

Resident Objectives:

ACGME Competency Goals

▪ Know the anatomy of the head and neck as seen on CT and MRI.

▪ Learn how to best interact with members of the radiology department.

Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Systems-Based Practice

▪ Spend at least two sessions observing a CT/MRI technologist to develop familiarity with scanning processes, radiation dosing and safety.

Medical Knowledge Patient Care

▪ Attend OHNS and neuroradiology education conferences

Medical Knowledge Practice Based Learning Patient Care

▪ Understand which type of imaging study is best for which type of clinical disorder.

▪ Understand the appearance of common head and neck disorders as seen on radiologic images.

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▪ Project: Assemble 10 to 15 cases of interest. These should be in PowerPoint format and presented as teachable cases. In his/her PGY2 year, the resident will present this at residency education session.

▪ Spend time in audiology a minimum of one afternoon/week learning about audiologic testing for all ages, hearing aids and cochlear implants.

▪ Learn the basics of audiology evaluation in adults. Be able to perform an audiogram.

▪ Learn and observe the types of audiologic testing in children.

▪ Understand the types of newborn hearing screens and the associated laws regarding screening.

▪ Observe the various types of vestibular testing and understand when each type is indicated.

▪ Learn to take a detailed vertigo/dizziness history.

▪ Become familiar with how to conduct a thorough vestibular physical exam ▪ Begin to understand the workup of a vestibular patient ▪ Obtain exposure to how to interpret results of vestibular/balance testing, including VEMP, VHIT, VNG, rotary chair, CDP ▪ Describe vestibular pathologies, both central and peripheral.

▪ Learn management options in the treatment of patients with dizziness.

▪ Attend or view online research training course

Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Medical Knowledge Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Systems-Based Practice Medical Knowledge Medical Knowledge Medical Knowledge Patient Care Medical Knowledge

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Stanford Health Care Headmirror Service Rotation Directors: Laryngology C. Kwang Sung, MD, MS kwangs@stanford.edu Weekly Schedule Monday

AM

PM

Sleep Medicine Robson Capasso, MD rcapasso@stanford.edu

Comprehensive Jennifer Lee, MD Jennifer.Y.Lee@stanford.edu

Tuesday

Wednesday

Thursday

Friday

Megwalu OR Sung clinic Lee clinic

Sung OR Capasso clinic (RWC) Lee OR Megwalu clinic

Capasso OR Lee clinic Liu clinic (RWC)

Dewan OR Damrose clinic Capasso clinic (RWC)

Damrose OR Sung OR (4th & 5th Fri)

Sung clinic Lee clinic

Sung procedure clinic Capasso clinic (RWC) Liu OR Megwalu clinic

Capasso OR Lee clinic Liu clinic (RWC)

Dewan OR Damrose clinic Capasso clinic (RWC)

Damrose OR Sung OR (4th & 5th Fri)

Goals and Objectives PGY 1: SHC Headmirror Service The PGY-1 will participate in otolaryngology rounds and under the direction of the chief/senior resident will be responsible for care of inpatients.

Call duties: The PGY1 resident will take call for in-house floor patients from 6:00 am until after rounds are complete and residents are released by the chief resident. On assigned weekends, they will take floor call during the day. PGY-1 residents will not take overnight call.

NOTE: All residents, including the PGY1 residents, will take the in-training exam on the first Saturday in March.

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Evaluation and Feedback The OHNS Faculty on the Headmirror Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1: Otolaryngology (“Headmirror”) Rotation: To be able to provide pre- and post-operative care for the otolaryngology surgical patient.

Resident Objectives: ACGME Competency Goals • Know the important aspects of history and physical examination of the otolaryngology Patient Care patient.

Medical Knowledge • Begin to understand the diagnosis and treatment of common otolaryngologic disorders.

Patient Care Medical Knowledge • Become familiar with the ACGME resident case log system.

Patient Care Medical Knowledge Systems-Based Practice • Demonstrate self-awareness and time management/organizational skills.

Practice-Based Learning and Improvement Goal 2: Otolaryngology (“Headmirror”) Rotation: To begin to develop otolaryngology surgical skills.

Resident Objectives: ACGME Competency Goals • Resident will know the names of common surgical instruments.

Patient Care • Resident will learn basic suturing and knot tying techniques.

• Resident will know how to set up the OR for routine otolaryngology cases.

• Resident will learn the basic techniques of Direct laryngoscopy, Esophagoscopy, Bronchoscopy.

• Resident will learn the basic techniques of DISE/flexible nasopharyngoscopy, inferior turbinate reduction, frenulotomy, archbar removal, tonsillectomy.

• Resident will gain experience by assisting with surgical procedures.

• Resident will be introduced to flexible laryngoscopy.

Goal 3: Otolaryngology (“Headmirror”) Rotation: To begin to organize a plan for a research project during residency.

Resident Objectives: ACGME Competency Goals • Meet with at least three faculty members about possible research projects during the Professionalism otolaryngology research rotation in the PGY3 year.

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Goals and Objectives PGY 2/3: SHC Headmirror Service

Rotation Contacts and Scheduling Details Please coordinate schedules and care with Attending Surgeons from Head and Neck Surgery (Capasso, Damrose, Dewan, Lee, Liu, Megwalu, Sung) Rotation Specifics 1.

2.

3.

4.

5.

6.

7.

8.

Rounding expectations: team is to round together in the morning with the chief resident leading. All members of the team are expected to know what is going on with each patient. On discharge, patients should have a date and time for follow-up. The team should establish this prior to discharge by calling the clinic or communicating with the P.A. The chief resident is expected to be teaching the juniors on rounds.

Communication with faculty regarding patients after rounds/weekends: • Communication of some sort is expected each day with each attending. For some, a text message is fine; for others, a phone call.

At the start of the service, the chief should establish the best mode of communication with each attending.

• When talking with patients, residents should avoid relaying care plans if there is uncertainty. They should tell the patient that they will check with the attending.

Communication with faculty regarding night-time contact with patients For serious issues (e.g. should a patient go back to the OR), it is ideal if calls go up the chain of command. R2s and R3s on call should call their chief resident to evaluate, who should notify the fellow, and then the attending. The R2 or R3 should NOT bypass senior residents and go directly to the attending. This is for teaching purposes.

Residents are expected to make entries into medical records for night-time patient contacts. A note should be entered into Epic for each contact with patients.

Residents should strike a balance between learning in the clinic and operating room. However, the chief resident should anticipate and plan in advance so that clinics can be covered as much as possible. This may require asking residents from other services to help. It may be advisable to limit vacation during the months of heavy R4 interviews.

A brief operative note should be entered within an hour of completion of the surgery by the resident. Dictation of operative reports: within 24 hours.

Preparation for OR: Discuss case with attending the day before. Read about the case. Know the patient and why the operation is being performed, the labs, etc.

When faculty is out of town, continue to communicate with attending daily if available by cell phone. If not, then, communicate with the covering attending or instructor (designated by the attending prior to leaving).

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Evaluation and Feedback The OHNS Faculty on the Headmirror Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1. Consults in an adult tertiary care hospital. Learn about the most common consults requested from other medical and surgical services regarding laryngeal and general otolaryngology problems in adults.

Resident Objectives:

ACGME Competency Goals

Be the initial contact person for all consults from other SHC services and the emergency department.

Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice Patient Care Medical Knowledge

Perform initial evaluation of all consult patients when designated and for all laryngology consults.

Be familiar with the SCH electronic medical record (EPIC) and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Evaluate consult patients with senior resident or fellow and faculty member and communicate recommendations and plan to primary team. Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems.

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills 33

Demonstrate effective time-management skills.

Follow-up on consult patients as needed.

Systems-Based Practice Practice-Based Learning and Improvement Professionalism Patient Care Systems-Based Practice Professionalism

Prepare and present at the weekly Head and Neck Case conference.

Medical Knowledge Systems-Based Practice Goal 2. Hoarseness. Screen, diagnose and manage patients with symptoms secondary to vocal fold/laryngeal pathology.

Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the larynx.

Take a history with focused questions that assist in the diagnosis of hoarseness.

Describe the use of diagnostic tests for assessing hoarseness (e.g. airway films, sleep studies, laryngeal endoscopy).

Be able on physical examination to assess dysfunction of vocal folds (ie, paralysis).

Describe how to identify a paralyzed vocal cord.

ACGME Competency Goals Medical Knowledge Patient Care Patient Care Medical Knowledge Patient Care Patient Care

Be able to counsel parents about the pathophysiology of conditions associated with vocal fold paralysis.

Patient Care Interpersonal and Communication Skills

Understand the indications for medialization (e.g., injection, thyroplasty) and alternative therapies.

Be able to counsel parents about the risks and benefits of vocal fold medialization.

Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Patient Care

Know the perioperative management and expected postoperative course of patients who undergo vocal fold medialization.

Be able to safely and efficiently perform a flexible fiberoptic nasolaryngoscopy.

Be able to discuss the treatment of and provide care to patients with complications of laryngoscopy.

Goal 3. Swallowing. Be able to evaluate and treat swallowing disorders in adults.

Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the pharynx and esophagus.

Patient Care Patient Care Interpersonal and Communication Skills ACGME Competency Goals Medical Knowledge 34

Be able to take a history related to the pharynx and esophagus as regards swallowing problems.

Understand the available treatments for dysphagia.

Be able to discuss the indications, risks, benefits and alternatives to dilation and to cricopharyngeal myotomy.

Be familiar with the endoscopic and open methods of treating Zenker’s diverticulum.

Understand the available bedside and radiographic methods of assessing swallowing.

Be able to discuss and treat complications from esophagoscopy.

Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Patient Care Medical Knowledge Patient Care Patient Care

Goal 4. Expand ability to perform surgical procedures Resident Objectives: ACGME Competency Goals Be able to competently and efficiently perform mid-level procedures with attending assistance Patient Care such as: • Direct laryngoscopy • Flexible and rigid Esophagoscopy.

• Injection laryngoplasty • Tonsillectomy • Septoplasty • Turbinate reduction • Tracheostomy • Panendoscopy • Submandibular gland excision • Excision of congenital cysts • Eustacian tube dilation • Resection of small carcinomas (e.g. tongue, floor of mouth) Goal 5. Sleep Medicine. Know about normal sleep/wake neurobiology and respiratory physiology Resident Objectives: ACGME Competency Goals Be familiar with the sleep/wake neural centers and connections associated with normal Medical Knowledge sleep/wake cycles.

Know the sleep stages and architecture.

Medical Knowledge Understand options for treatment of nasal septal deviation and turbinate hypertrophy..

Medical Knowledge 35

Patient Care Goal 6. Know about common sleep disorders and their consequences Resident Objectives: Be able to define and describe the following sleep disorders: • Sleep related breathing disorders (SRBD) • Insomnia • Circadian rhythm sleep disorders • Hypersomnias, parasomnias and sleep related movement disorders • Insufficient sleep syndrome.

ACGME Competency Goals Medical Knowledge Patient Care

Goal 7. Know how to obtain a sleep history and comprehensive physical examination in patients with sleep complaints Resident Objectives: ACGME Competency Goals Be able to obtain a sleep history including the ability to identify associated co-morbidities Patient Care from poor sleep: mood and cognitive dysfunction, hypertension, atrial fibrillation, Interpersonal and Communication Skills cerebrovascular accidents.

Know the Epworth sleepiness scale and be able to administer and interpret the results.

Patient Care Interpersonal and Communication Skills Be able to identify craniofacial and soft tissue abnormalities associated with SRBD. Patient Care Interpersonal and Communication Skills Goal 8. Understand the options for evaluating patients with sleep disorders and how to interpret the appropriate clinical studies.

Resident Objectives: ACGME Competency Goals Understand technological tools involved in polysomnographic and home monitoring devices, including EEG, EMG, EOG, EKG, airflow sensors, respiratory effort belts, oximetry/gas monitoring, esophageal pressure, arterial pletismography.

Medical Knowledge

Be able on a polysomnogram to identify respiratory events including apneas/hypopneas, RERAs and hypoventilation.

Medical Knowledge

Understand the indications and interpretation of the multiple sleep latency test.

Understand the use of imaging studies in patients with sleep disorders.

Goal 9. Improve general otolaryngology knowledge

Medical Knowledge Medical Knowledge

Resident Objectives:

ACGME Competency Goals Patient Care 36

Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds.

Learn to set-up and use the facial nerve integrity monitor.

Demonstrate competence in the safe and appropriate use of various lasers.

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

Medical Knowledge Patient Care Patient Care Patient Care Systems-Based Practice Patient Care Systems-Based Practice Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement

37

Goals and Objectives PGY 4: SHC Headmirror Service

Rotation Contacts and Scheduling Details Please coordinate schedules and care with Attending Surgeons (Capasso, Damrose, Dewan, Lee, Liu, Megwalu, Sung) Note: if there is no O.R. going on (e.g. attending physician is out of town), the resident is expected to attend clinic.

Rotation Specifics 1. Rounding expectations: team is to round together in the morning with the chief resident leading. All members of the team are expected to know what is going on with each patient. On discharge, patients should have a date and time for follow-up. The team should establish this prior to discharge by calling the clinic or communicating with the P.A. The chief resident is expected to be teaching the juniors on rounds.

2. Communication with faculty regarding patients after rounds/weekends: • Communication of some sort is expected each day with each attending. For some, a text message is fine; for others, a phone call. At the start of the service, the chief should establish the best mode of communication with each attending.

• When talking with patients, residents should avoid relaying care plans if there is uncertainty. They should tell the patient that they will check with the attending.

3. Communication with faculty regarding night-time contact with patients 4. For serious issues (e.g. should a patient go back to the OR), it is ideal if calls go up the chain of command. R2s on call should call their chief resident to evaluate, who should notify the fellow, and then the attending. The R2 should NOT bypass senior residents and go directly to the attending. This is for teaching purposes.

5. Residents are expected to make entries into medical records for night-time patient contacts. A note should be entered into Epic for each contact with patients.

6. Residents should strike a balance between learning in the clinic and operating room. However, the chief resident should anticipate and plan in advance so that clinics can be covered as much as possible. This may require asking residents from other services to help. It may be advisable to limit vacation during the months of heavy R4 interviews.

7. A brief operative note should be entered within an hour of completion of the surgery by the resident. Dictation of operative reports: within 24 hours.

8. Preparation for OR: Discuss case with attending the day before. Read about the case. Know the patient and why the operation is being performed, the labs, etc.

9. When faculty is out of town, continue to communicate with attending daily if available by cell phone. If not, then, communicate with the covering attending or instructor (designated by the attending prior to leaving).

38

Evaluation and Feedback The OHNS Faculty on the Headmirror Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1. Expand knowledge in the area of laryngeal oncology Resident Objectives: Be able to identify clinically suspicious lesions of the larynx and esophagus, perform appropriate biopsies and imaging studies to make a diagnosis in a cost effective and time efficient manner.

Understand risk factors for head and neck cancer, be able to assess patients for risk factors and be able to counsel patients about managing the risk factors.

ACGME Competency Goals Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge Interpersonal and Communication Skills

Be able to acquire appropriate information to stage laryngeal cancers, to present cases in the Head and Neck Tumor Board and to determine the best treatment modality or modalities. When presenting the cases in Tumor Board, up-to-date literature will be used to support treatment decisions.

Be able to discuss the treatment options with the patient and make the appropriate consultations (medical oncology, radiation oncology, dentistry, speech pathology, physical therapy, nutrition, and or social work) based on the patient’s needs and wishes.

This will require consideration of the patient’s rights and a sensitivity to cultural, age, gender and disability issues.

Administer care for the post-operative oncology patient.

Patient Care Professionalism Systems-Based Practice

Be able to describe principles about and perform interventions for early laryngeal cancer.

Be able to perform interventions for advanced laryngeal cancer.

Professionalism Practice-Based Learning and Improvement Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Goal 2: Be competent in evaluating and managing otolaryngology patients.

Resident Objectives:

ACGME Competency Goals

39

Expand and refine evaluation and management skills of otolaryngology patients. Such knowledge should allow the R4 resident to confidently and independently care for otolaryngology patients by the end of the year.

Medical Knowledge Patient Care

Expand participation to include a leadership role in teaching conferences facilitating the learning of the junior residents and medical students.

Practice-Based Learning and Improvement Interpersonal and Communication Skills Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge

Expand knowledge of Otolaryngology literature for diseases and disorders of the larynx and sleep surgery.

Understand the limits of surgical and medical treatment.

Understand indications for urgent operative decisions, such as a performing a surgical airway and decompressing an expanding neck hematoma Recognize and manage surgical risk-factors.

Administer care for the post-operative patient.

Expand the capacity to recognize and treat post-surgical complications effectively, and learn to recognize preoperative risk factors.

Gain a healthy appreciation for the dangers inherent in medical intervention, and learn how to be appropriate in selecting patients for surgery.

Assume a leadership role in postoperative care of complications such as salivary fistula, wound infection, hematoma, cerebrospinal fluid leak, airway compromise, and hemorrhage. Teach the junior residents and medical students to manage these complications.

Be able to successfully transition from supervision by faculty to primary decision making with faculty oversight.

Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Practice-Based Learning and Improvement Patient Care Patient Care

40

Supervise presentation of complications on the service at monthly Morbidity and Mortality conference.

Practice-Based Learning and Improvement

Demonstrate competence and organizational skills in directing the resident team in the daily management of in-house patients and OR activities.

Practice-Based Learning and Improvement

Demonstrate ability and commitment in the day-to-day informal teaching and mentoring of students and junior residents.

Practice-Based Learning and Improvement

Be able to competently supervise/assist junior residents performing common OTO/HNS surgical procedures.

Be able to demonstrate excellent interpersonal skills, effectively setting the tone for other members of the resident team, clinical and non-clinical staff.

Practice-Based Learning and Improvement Professionalism

Goal 3. Airway. Be able to evaluate and form treatment plans for adults with airway obstruction due upper airway and tracheal lesions.

Resident Objectives: ACGME Competency Goals Be able to describe the anatomy, physiology, and pathophysiology of the larynx.

Medical Knowledge

Be able to recognize, describe and categorize stridor in adults. Know the most common causes of stridor and dyspnea in adults.

Patient Care Medical Knowledge

Be able to describe the various methods for managing a complex airway patient (i.e. awake fiberoptic intubation, hi-flow nasal cannula, jet ventilation, laryngeal mas airway, rigid bronchoscopy, awake tracheostomy); their indications and their possible complications.

Be able to discuss routine care of a tracheostomy and describe how to recognize tracheostomy obstruction or decannulation. Be able to educate a patient about the risks/benefits and care of a tracheostomy. Be knowledgeable about how to obtain the needed tracheostomy related equipment for patient use at home.

Patient Care

Be familiar with the principal lesions that can affect vocal fold function in adults (i.e. papilloma, polyp, nodule, cancer).

Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to identify the various methods for laryngeal framework surgery (e.g. thyroplasty, arytenoids adduction); their indications and their possible complications.

Patient Care Medical Knowledge Interpersonal and Communication Skills Systems-Based Practice

41

Know the instrumentation used to resect laryngeal lesions (i.e. endoscopic scissors, Patient Care graspers, laser).

Goal 4. Videostroboscopy. Be able to utilize and to interpret videostroboscopy in the diagnosis of laryngeal disorders.

Resident Objectives: Be familiar with the setup and technique of videostroboscopy.

ACGME Competency Goals Patient Care Medical Knowledge

Understand the various components of laryngeal function which can be assessed with videostroboscopy (ie, vocal fold waveform, amplitude, glottic gap, etc).

Patient Care Medical Knowledge Patient Care Medical Knowledge

Recognize the characteristic features of various disorders as diagnosed by videostroboscopy (ie, nodules, polyps, cysts, granulomas, spasmodic dysphonia).

Goal 5. Sleep Medicine. Be able to effectively evaluate and treat a patient with a sleep related breathing disorder.

Resident Objectives:

ACGME Competency Goals

Know the indications for PAP therapy, and different modalities including CPAP, auto PAP, BiPAP, Auto BIPAP, AVAPS, and ASV.

Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills

Evaluate and stimulate PAP compliance through clinical history and data downloaded from PAP machine.

Understand and be able to recommend methods to improve PAP compliance including mask refitting, use of EPR, referral to behavioral desensitization.

Be able to integrate with other members of a sleep center, and know how to adequately refer patients for medical, dental, and behavioral management of sleep disorders.

Be able to analyze data from the history, physical examination, sleep test, nasal endoscopy, drug induced sleep endoscopy, and imaging tests and identify who will benefit from some sort of therapy and which therapy should be recommended.

Be able to select appropriate candidates for oral device therapy.

Be able to inform the patient about weight loss, behavioral and positional management of SRBD.

Patient Care Interpersonal and Communication Skills Systems-Based Practice Patient Care Systems-Based Practice Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills

42

Be able to ethically and thoroughly provide all available data to patients and help him/her make the best possible decision on surgical care of OSA. Understand the indications, role and realistic goals of surgery. Be able to perform an adequate psychosocial assessment and explain why no surgical intervention may be the best choice for some patients. Be able to formulate an independent plan for surgical management of obstructive sleep apnea. Performing septoplasty, turbinate reduction, uvulopalatopharyngoplasty.

Understand the indications, techniques, benefits and risks of sleep surgery involving the facial skeleton (maxillomandibular advancement, maxillary expansion/DOME, genioglossus advancement). Performing critical parts of the procedure. Incorporate virtual surgical planning.

Understand the inclusion criteria of hypoglossal nerve stimulation. Performing critical Parts of the procedure. Understand the activation protocol after implantation.

Understand and describe risks and complications of OSA surgery, including voice and swallowing changes, complex pain management, facial paresthesias, infection, need for HGNS explant, facial profile and cosmetic changes and need for revision surgery. Be able to effectively and compassionately counsel patients of these details.

Effectively and comprehensively manage primary inhouse, post-operative and consult patients with obstructive sleep apnea with the junior and senior residents.

Patient Care Interpersonal and Communication Skills Professionalism Patient Care Interpersonal and Communication Skills Professionalism Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge

Demonstrate appropriate surgical technique for uvulopalatopharyngoplasty, be able to perform most of the cervical approach in hypoglossal nerve stimulation cases. Be able to perform Lefort osteotomies during maxillomandibular advancement Goal 6. Improve competency in the performance of laryngology, sleep, and general otolaryngology surgeries Resident Objectives: Be adept in performing the following procedures: · Diagnostic endoscopy · Operative microlaryngoscopy · Tracheotomy · Salivary gland resections

ACGME Competency Goals Patient Care

43

· Endoscopic dilatation and CO2 laser resection for subglottic stenosis and posterior glottic stenosis · Uvulopalatopharyngoplasty and its multiple modifications · Tongue surgery-volume reduction and/or tongue suspension/suture Become increasingly skilled in performing the following procedures: · Neck Dissection · Laryngectomy (total and partial) · Laryngopharyngectomy · Parotidectomy · Thyroidectomy · Parathyroidectomy · Type I thyroplasty · Arytenoid adduction · Cricotracheal resection · Tracheal resection · Maxillomandibular advancement, maxillary expansion/DOME, genioglossus advancement · Hypoglossal nerve stimulator implant Know the indications, perioperative care, expected outcomes and possible complications for all procedures listed above.

Patient Care

Patient Care

Demonstrate competence in the safe and appropriate use of various lasers.

Patient Care Goal 6. Be able to take care of patients in an ethical, efficient and caring manner within the current medical system Resident Objectives: Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds.

ACGME Competency Goals Patient Care

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Systems-Based Practice Professionalism Patient Care

44

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Prepare and guide junior residents presentation at weekly Head and Neck Case conference.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Interpersonal and Communication Skills Systems-Based Practice Professionalism Professionalism Interpersonal and Communication Skills Professionalism Practice-Based Learning and Improvement Medical Knowledge Systems-Based Practice Medical Knowledge Practice-Based Learning and Improvement

45

Stanford Health Care Scalpel Service Rotation Director: Chris Holsinger, MD holsinger@stanford.edu Goals and Objectives PGY 1: SHC Scalpel Service The PGY-1 will participate in otolaryngology rounds and under the direction of the chief/senior resident will be responsible for care of inpatients.

Call duties: The PGY1 resident will take call for in-house floor patients from 6:00 am until after rounds are complete and residents are released by the chief resident. On assigned weekends, they will take floor call during the day. PGY-1 residents will not take overnight call.

NOTE: All residents, including the PGY1 residents, will take the in-training exam on the first Saturday in March.

Evaluation and Feedback The OHNS Faculty on the Scalpel Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1: Otolaryngology (“Scalpel”) Rotation: To be able to provide pre- and post-operative care for the otolaryngology surgical patient.

Resident Objectives:

ACGME Competency Goals

• Know the important aspects of history and physical examination of the otolaryngology patient.

• Begin to understand the diagnosis and treatment of common otolaryngologic disorders.

Patient Care Medical Knowledge Patient Care Medical Knowledge

• Become familiar with the ACGME resident case log system.

Patient Care Medical Knowledge Systems-Based Practice Practice-Based Learning and Improvement Medical Knowledge Systems-Based Practice

• Demonstrate self-awareness and time management/organizational skills.

• Prepare and present at the weekly Head and Neck Case conference

46

Goal 2: Otolaryngology (“Scalpel”) Rotation: To begin to develop otolaryngology surgical skills.

Resident Objectives: ACGME Competency Goals • Resident will know the names of common surgical instruments.

Patient Care • Resident will learn basic suturing and knot tying techniques.

• Resident will know how to set up the OR for routine otolaryngology cases.

• Resident will learn the basic techniques of Direct laryngoscopy, Esophagoscopy, Bronchoscopy.

• Resident will gain experience by assisting with surgical procedures.

• Resident will be introduced to flexible laryngoscopy.

Goal 3: Otolaryngology (“Scalpel”) Rotation: To begin to organize a plan for a research project during residency.

Resident Objectives: ACGME Competency Goals • Meet with at least three faculty members about possible research projects during the Professionalism otolaryngology research rotation in the PGY3 year.

Goals and Objectives PGY 2/3: SHC Scalpel Service

Rotation Contacts and Scheduling Details Please coordinate schedules and care with Attending Surgeons from Head and Neck Surgery (Baik, Divi, Holsinger, Kaplan, Noel, Orloff, Rosenthal, Sirjani, Sunwoo) Rotation Specifics 9.

Rounding expectations: team is to round together in the morning with the chief resident leading. All members of the team are expected to know what is going on with each patient. On discharge, patients should have a date and time for follow-up. The team should establish this prior to discharge by calling the clinic or communicating with the P.A. The chief resident is expected to be teaching the juniors on rounds.

10. Communication with faculty regarding patients after rounds/weekends: • Communication of some sort is expected each day with each attending. For some, a text message is fine; for others, a phone call.

At the start of the service, the chief should establish the best mode of communication with each attending.

• When talking with patients, residents should avoid relaying care plans if there is uncertainty. They should tell the patient that they will check with the attending.

11. Communication with faculty regarding night-time contact with patients 47

For serious issues (e.g. should a patient go back to the OR), it is ideal if calls go up the chain of command. R2s on call should call their chief resident to evaluate, who should notify the fellow, and then the attending. The R2 should NOT bypass senior residents and go directly to the attending. This is for teaching purposes.

12. Residents are expected to make entries into medical records for night-time patient contacts. A note should be entered into Epic for each contact with patients.

13. Residents should strike a balance between learning in the clinic and operating room. However, the chief resident should anticipate and plan in advance so that clinics can be covered as much as possible. This may require asking residents from other services to help. There should never be a chief and the R4 gone at the same time. It may be advisable to limit vacation during the months of heavy R4 interviews.

14. A brief operative note should be entered within an hour of completion of the surgery by the resident. Dictation of operative reports: within 24 hours.

15. Preparation for OR: Discuss case with attending the day before. Read about the case. Know the patient and why the operation is being performed, the labs, etc.

16. When faculty is out of town, continue to communicate with attending daily if available by cell phone. If not, then, communicate with the covering attending or instructor (designated by the attending prior to leaving).

17. The resident is required to attend the Thursday H&N teaching conference (H&N team). At this conference, the PGY-2 will present a case assigned by the chief resident and know the tumor stage and basic management strategies.

18. The resident will also attend H&N tumor board in addition to the regularly scheduled resident education conferences.

Evaluation and Feedback The OHNS Faculty on the Scalpel Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation.

Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1. Expand knowledge in area of head and neck oncology.

Resident Objectives: Be able to accurately stage cancers of the head and neck.

ACGME Competency Goals Medical Knowledge

Develop an understanding of the role of chemotherapy and radiation therapy in the treatment of head and neck cancer.

Patient Care Medical Knowledge Patient Care Medical Knowledge 48

Begin to be able to formulate a treatment plan for head and neck tumors with supervision, and be able to effectively counsel patients regarding treatment options including risks associated with surgical treatment.

Progress in ability to counsel patients regarding head and neck cancer risk factors.

Develop an understanding of the role of surgery in the treatment of squamous cell carcinoma of the head and neck.

Begin to understand the appropriate surgical procedures for the treatment of head and neck cancers.

Be able to work-up and treat patients with thyroid and parathyroid diseases.

Be able to work-up and treat patients with melanoma of the head and neck.

Be able to work-up and treat patients with salivary gland tumors.

Interpersonal and Communication Skills Practice-Based Learning and Improvement Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to recognize the histopathologic appearance of common head and neck neoplasms, Medical Knowledge including parotid and thyroid pathology.

Goal 2. Consults in an adult tertiary care hospital. Learn about the most common consults requested from other medical and surgical services regarding laryngeal problems in adults.

Resident Objectives:

ACGME Competency Goals

Be the initial contact person for all consults from other SHC services and the emergency department.

Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice Patient Care Medical Knowledge Patient Care

Perform initial evaluation of all consult patients.

49

Be familiar with the SCH electronic medical record (EPIC) and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Evaluate consult patients with senior resident or fellow and faculty member and communicate recommendations and plan to primary team. Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems.

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

Demonstrate effective time-management skills.

Follow-up on consult patients as needed.

Prepare and present at the weekly Head and Neck Case conference.

Goal 3. Expand ability to perform head and neck surgical procedures Resident Objectives: Be able to competently and efficiently perform mid-level procedures with attending assistance such as: • Direct laryngoscopy and biopsy • Flexible and rigid esophagoscopy.

• Tonsillectomy • Tracheostomy • Panendoscopy • Submandibular gland excision • Excision of congenital cysts

Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice Practice-Based Learning and Improvement Professionalism Patient Care Systems-Based Practice Professionalism Medical Knowledge Systems-Based Practice ACGME Competency Goals Patient Care

50

• • • • •

Resection of small carcinomas (e.g. tongue, floor of mouth) Resection of melanoma of the head and neck Sentinel lymph node biopsy Skin graft and flap reconstruction of head and neck defects Assist with neck dissections and begin to understand the anatomy and principles governing neck dissections

Goal 4. Improve general otolaryngology knowledge Resident Objectives: Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds.

Learn to set-up and use the facial nerve integrity monitor.

Demonstrate competence in the safe and appropriate use of various lasers.

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

ACGME Competency Goals Patient Care Medical Knowledge Patient Care Patient Care Patient Care Systems-Based Practice Patient Care Systems-Based Practice Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement

51

Goals and Objectives PGY 4: SHC Scalpel Service

Rotation Contacts and Scheduling Details Please coordinate schedules and care with Attending Surgeons from Head and Neck Surgery (Baik, Divi, Holsinger, Kaplan, Noel, Orloff, Rosenthal, Sirjani, Sunwoo) Note: if there is no O.R. going on (e.g. attending physician is out of town), the resident is expected to attend clinic.

Rotation Specifics 10. Rounding expectations: team is to round together in the morning with the chief resident leading. All members of the team are expected to know what is going on with each patient. On discharge, patients should have a date and time for follow-up. The team should establish this prior to discharge by calling the clinic or communicating with the P.A. The chief resident is expected to be teaching the juniors on rounds.

11. Communication with faculty regarding patients after rounds/weekends: • Communication of some sort is expected each day with each attending. For some, a text message is fine; for others, a phone call. At the start of the service, the chief should establish the best mode of communication with each attending.

• When talking with patients, residents should avoid relaying care plans if there is uncertainty. They should tell the patient that they will check with the attending.

12. Communication with faculty regarding night-time contact with patients 13. For serious issues (e.g. should a patient go back to the OR), it is ideal if calls go up the chain of command. R2s on call should call their chief resident to evaluate, who should notify the fellow, and then the attending. The R2 should NOT bypass senior residents and go directly to the attending. This is for teaching purposes.

14. Residents are expected to make entries into medical records for night-time patient contacts. A note should be entered into Epic for each contact with patients.

15. Residents should strike a balance between learning in the clinic and operating room. However, the chief resident should anticipate and plan in advance so that clinics can be covered as much as possible. This may require asking residents from other services to help. There should never be a chief and the R4 gone at the same time. It may be advisable to limit vacation during the months of heavy R4 interviews.

16. A brief operative note should be entered within an hour of completion of the surgery by the resident. Dictation of operative reports: within 24 hours.

17. Preparation for OR: Discuss case with attending the day before. Read about the case. Know the patient and why the operation is being performed, the labs, etc.

18. When faculty is out of town, continue to communicate with attending daily if available by cell phone. If not, then, communicate with the covering attending or instructor (designated by the attending prior to leaving).

52

19. Resident are required to attend the Thursday H&N teaching conference (H&N team) and tumor board in addition to the regularly scheduled resident education conferences.

Evaluation and Feedback The OHNS Faculty on the Scalpel Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation.

Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

Competency-based Goals and Objectives Goal 1. Expand knowledge in the area of head & neck surgery, as well as general concepts in surgical oncology Resident Objectives: ACGME Competency Goals Be able to identify clinically suspicious lesions of the head and neck, perform appropriate biopsies and imaging studies to make a diagnosis in a cost effective and time efficient manner.

Understand risk factors for head and neck cancer, be able to assess patients for risk factors and be able to counsel patients about managing the risk factors.

Be able to acquire appropriate information to stage head and neck cancers, to present cases in the Head and Neck Tumor Board and to determine the best treatment modality or modalities.

When presenting the cases in Tumor Board, up-to-date literature will be used to support treatment decisions.

Be able to discuss the treatment options with the patient and make the appropriate consultations (medical oncology, radiation oncology, dentistry, speech pathology, physical therapy, nutrition, and or social work) based on the patient’s needs and wishes. This will require consideration of the patient’s rights and a sensitivity to cultural, age, gender and disability issues.

Become more familiar with ablative and reconstructive options.

Understand the role of adjuvant therapy.

Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Professionalism Systems-Based Practice Professionalism Practice-Based Learning and Improvement Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Systems-Based Practice Practice-Based Learning and Improvement

53

Be able to work-up and treat patients with thyroid and parathyroid diseases. Become familiar with the endocrinology of these disorders and how to decide when intervention is appropriate.

Learn the fundamentals of neck ultrasound, to include optimization of machine settings and accurate identification of pathology.

Be able to work-up and treat patients with melanoma of the head and neck.

Patient Care Medical Knowledge

Be able to work-up and treat patients with salivary gland tumors.

Patient Care Medical Knowledge Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge

Prepare and present at the weekly Head and Neck Case conference.

Administer care for the post-operative oncology patient.

Patient Care Medical Knowledge Patient Care Medical Knowledge

Goal 2. Improve competency in the performance of head and neck surgeries Resident Objectives: Be adept in performing the following procedures: · Diagnostic endoscopy · Operative microlaryngoscopy · Tracheotomy · Oral cavity cancer resections · Removal of skin cancers · Sentinel lymph node biopsy Become increasingly skilled in performing the following procedures: · Neck Dissection · Laryngectomy (total and partial) · Laryngopharyngectomy · Composite resection · Regional flaps for reconstruction · Maxillectomy · Parotidectomy

ACGME Competency Goals Patient Care

Patient Care

54

· Thyroidectomy · Parathyroidectomy Know the indications, perioperative care, expected outcomes and possible complications for all procedures listed above.

Patient Care

Demonstrate competence in the safe and appropriate use of various lasers.

Patient Care Goal 4. Be able to take care of patients in an ethical, efficient and caring manner within the current medical system Resident Objectives: Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds.

ACGME Competency Goals Patient Care

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Systems-Based Practice

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Prepare and guide junior residents presentation at weekly Head and Neck Case conference.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

Professionalism Patient Care Interpersonal and Communication Skills Systems-Based Practice Professionalism Professionalism Interpersonal and Communication Skills Professionalism Practice-Based Learning and Improvement Medical Knowledge Systems-Based Practice Medical Knowledge Practice-Based Learning and Improvement

55

Goals and Objectives PGY 5: SHC Scalpel Service

Rotation Contacts and Scheduling Details Please coordinate schedules and care with Attending Surgeons from Head and Neck Surgery (Baik, Divi, Holsinger, Kaplan, Noel, Orloff, Rosenthal, Sirjani, Sunwoo) Note: if there is no O.R. going on (e.g. attending physician is out of town) resident is expected to attend clinic.

Rotation Specifics 1. Rounding expectations: team is to round together in the morning with the chief resident leading. All members of the team are expected to know what is going on with each patient. On discharge, patients should have a date and time for follow-up. The team should establish this prior to discharge by calling the clinic or communicating with the P.A. The chief resident is expected to be teaching the juniors on rounds.

2. Communication with faculty regarding patients after rounds/weekends: 3. Communication of some sort is expected each day with each attending. For some, a text message is fine; for others, a phone call. At the start of the service, the chief should establish the best mode of communication with each attending.

4. When talking with patients, residents should avoid relaying care plans if there is uncertainty. They should tell the patient that they will check with the attending.

5. Communication with faculty regarding night-time contact with patients 6. For serious issues (e.g. should a patient go back to the OR), it is ideal if calls go up the chain of command. R2s on call should call their chief resident to evaluate, who should notify the fellow, and then the attending. The R2 should NOT bypass senior residents and go directly to the attending. This is for teaching purposes.

7. Residents are expected to make entries into medical records for night-time patient contacts. A note should be entered into Epic for each contact with patients.

8. Residents should strike a balance between learning in the clinic and operating room. However, the chief resident should anticipate and plan in advance so that clinics can be covered as much as possible. This may require asking residents from other services to help. There should never be a chief and the R4 gone at the same time. It may be advisable to limit vacation during the months of heavy R4 interviews.

9. A brief operative note should be entered within an hour of completion of the surgery by the resident. Dictation of operative reports: within 24 hours.

10. Preparation for OR: Discuss case with attending the day before. Read about the case. Know the patient and why the operation is being performed, the labs, etc.

11. When faculty is out of town, continue to communicate with attending daily if available by cell phone. If not, then, communicate with the covering attending or instructor (designated by the attending prior to leaving).

12. The resident is required to attend the Thursday H&N teaching conference (H&N team). At this conference, the chief resident will assign upcoming cases to junior residents. He/she will also participate in this conference by answering faculty questions regarding 56

13. Resident are required to attend the Thursday H&N teaching conference (H&N team) and tumor board in addition to the regularly scheduled resident education conferences.

14. Chief resident is expected to attend the monthly faculty meeting.

Evaluation and Feedback The OHNS Faculty on the Scalpel Service (and selected ancillary medical personnel) will complete written evaluations at the end of the rotation.

Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each faculty member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions Competency-based Goals and Objectives Goal 1: Be competent in evaluating and managing head & neck otolaryngology patients.

Resident Objectives: Expand and refine evaluation and management skills of otolaryngology patients. Such knowledge should allow the R5 resident to confidently and independently care for otolaryngology patients with conditions involving head and neck oncology by the end of the year.

Expand participation to include a leadership role in teaching conferences facilitating the learning of the junior residents and medical students.

ACGME Competency Goals Medical Knowledge Patient Care

Expand knowledge of Otolaryngology literature for diseases and disorders of the larynx and cancers of the head and neck.

Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge Practice-Based Learning and Improvement Systems-Based Practice Interpersonal and Communication Skills Professionalism

Be able to identify clinically suspicious lesions of the head and neck, perform appropriate biopsies and imaging studies to make to make a diagnosis in a cost effective and time efficient manner.

Be able to acquire appropriate information to stage head and neck cancers, to present cases in the Head and Neck Tumor Board and to determine the best treatment modality or modalities.

When presenting the cases in Tumor Board, up to date literature will be used to support treatment decisions. Be able to discuss the treatment options with the patient and make the appropriate consultations (medical oncology, radiation oncology, dentistry, speech pathology, physical therapy, nutrition and/or social work) based on the patient wishes. This will require consideration of the patient’s rights and a sensitivity to cultural, age, gender, and disability issues.

Practice-Based Learning and Improvement Interpersonal and Communication Skills

57

Demonstrate competency in performing comprehensive neck ultrasound to assist in diagnosis, surgical planning, and image guided procedures. Be able to recognize common pathologies (thyroid nodules/cysts, malignancy, normal and abnormal lymph nodes, parathyroid adenoma, ranula, thyroglossal duct cyst).

Patient Care

Develop a comprehensive understanding of the common ablative and reconstructive options.

Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Understand the limits of surgical and medical treatment.

Understand the role of adjuvant therapy.

Understand indications for urgent operative decisions, such as a performing a surgical airway and decompressing an expanding neck hematoma Recognize and manage surgical risk-factors.

Administer care for the post-operative oncology patient.

Expand the capacity to recognize and treat post-surgical complications effectively, and learn to recognize preoperative risk factors.

Medical Knowledge

Patient Care Medical Knowledge Patient Care Medical Knowledge

Gain a healthy appreciation for the dangers inherent in medical intervention, and learn how to be appropriate in selecting patients for surgery.

Patient Care Medical Knowledge Practice-Based Learning and Improvement

Assume a leadership role in postoperative care of complications such as salivary fistula, wound infection, hematoma, cerebrospinal fluid leak, airway compromise, and hemorrhage.

Teach the junior residents and medical students to manage these complications.

Patient Care Practice-Based Learning and Improvement

Be able to effectively incorporate radiologic studies in assessing patients with head and neck tumors in a cost effective and time efficient manner.

Patient Care Medical Knowledge Systems-Based Practice

Be able to successfully transition from supervision by faculty to primary decision making with faculty oversight.

Patient Care Patient Care 58

Supervise presentation of complications on the service at monthly Morbidity and Mortality conference.

Practice-Based Learning and Improvement

Demonstrate competence and organizational skills in directing the resident team in the daily management of in-house patients and OR activities.

Practice-Based Learning and Improvement

Demonstrate ability and commitment in the day-to-day informal teaching and mentoring of students and junior residents.

Practice-Based Learning and Improvement

Be able to competently supervise/assist junior residents performing common OTO/HNS surgical procedures.

Be able to demonstrate excellent interpersonal skills, effectively setting the tone for other members of the resident team, clinical and non-clinical staff.

Practice-Based Learning and Improvement Professionalism

Goal 2: Be able to safely and efficiently perform advanced head & neck surgical skills.

Resident Objectives: Refine operative skills and gain expertise in advanced surgical procedures of the head and neck, as well as laryngology. The R5 Otolaryngology residents are expected to assume a graduated responsibility in more complex operative cases. Through their rotation they should become comfortable with taking an active role in the technical procedures such as: •

•

•

ACGME Competency Goals Patient Care

Head and Neck Surgery o Neck Dissection o Laryngectomy (total and partial) o Laryngopharyngectomy o Composite resection Endocrine Surgery o Thyroidectomy o Parathyroidectomy o Central neck dissection Reconstructive Surgery o Regional flaps for reconstruction o Maxillectomy o Anterior skull base resection o Parotidectomy o Oral cavity cancer resections 59

o Melanoma of the head and neck o Sentinel lymph node biopsy Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Patient Care Systems-Based Practice Patient Care Systems-Based Practice Professionalism Systems-Based Practice Practice-Based Learning and Improvement Practice-Based Learning and Improvement

HALF-TIME RESEARCH RESIDENT • Research Resident must have at least 2.5 days of research time per week on average.

• During PGY2/3 or PGY4’s vacation/conference/interview period, Half-time Research Resident usually works as full time.

60

Lucile Packard Children’s Hospital Stanford Goals and Objectives Welcome to the Pedi OHNS Rotation!

Rotation Director:

Iram Ahmad, MD, MME ahmadin@stanford.edu

Faculty: Ahmad, Balakrishnan, Chang, Cheng, Koltai, Meister, Sidell, Truong, Valdez Rotation Specifics: Please refer to Peds Service Guidelines provided by the service.

Goals and Objectives PGY 1: PEDIATRIC Otolaryngology NOTE: All residents, including the PGY1 residents, will take the in-training exam on the first Saturday in March.

Competency-based Goals and Objectives Goal 1. Pediatric Otolaryngology Hospital service. Learn the common pediatric otolaryngology disorders which require children to be in the hospital, the basics of how to manage these patients, and basic surgical skills.

Resident Objectives: Round with the pediatric otolaryngology team 2 times a day and know the common entities that require a child to be hospitalized.

Learn the basics of how to perform flexible laryngoscopy on a child. Learn how to operate the Machinery on the scope cart.

Be familiar with the LPCH electronic medical record (EPIC) and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Perform a literature search to learn more about unusual patient problems.

ACGME Competency Goals Patient Care Medical Knowledge Interpersonal and Communication Skills Systems-Based Practice Patient Care Systems-Based Practice Patient Care Professionalism Systems-Based Practice Medical Knowledge Practice-Based Learning and Improvement 61

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the hospital setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

Demonstrate effective time-management skills.

Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Professionalism Systems-Based Practice Practice-Based Learning and Improvement

Begin to acquire the following surgical skills:

Suturing and knot tying techniques.

Patient Care Microscope set up.

Cerumen removal.

Tonsillectomy and Adenoidectomy steps.

Myringotomy and tube placement steps.

Goal 2. Pediatric Otolaryngology Clinics. Learn the common pediatric otolaryngology disorders seen in pediatric otolaryngology clinics and how to evaluate these patients.

Resident Objectives: Learn how to evaluate a child with sleep-disordered breathing.

Learn how to evaluate a child with recurrent ear infections.

Practice pneumatic otoscopy.

Learn how to evaluate a pediatric neck mass, particularly congenital neck masses.

ACGME Competency Goals Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge

Goals and Objectives PGY 2/3: PEDIATRIC Otolaryngology Competency-based Goals and Objectives Goal 1. Consults in a pediatric hospital. Learn about the most common consults requested from other medical and surgical services regarding otolaryngology problems in children.

Resident Objectives: Be the initial contact person for all consults from other LPCH services and the emergency department.

ACGME Competency Goals Patient Care Medical Knowledge Interpersonal and Communication Skills 62

Perform initial evaluation of all consult patients.

Be familiar with the LPCH electronic medical record (EPIC) and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Evaluate consult patients with senior resident or fellow and faculty member and communicate recommendations and plan to primary team. Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems.

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

Demonstrate effective time-management skills.

Follow-up on consult patients as needed.

Systems-Based Practice Patient Care Medical Knowledge Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Professionalism Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice Professionalism Practice-Based Learning and Improvement Patient Care Systems-Based Practice Professionalism

Attend at least one “care conference” Systems-Based Practice Goal 2. Tonsillar and Adenoidal Hypertrophy. Screen, diagnose and manage patients with symptoms secondary to their tonsils and adenoids Resident Objectives: ACGME Competency Goals Be able to describe the anatomy, physiology, and pathophysiology of the tonsils/adenoids/eustachian tube.

Take a sleep history with focused questions that assist in the diagnosis of sleep apnea.

Medical Knowledge Patient Care 63

Describe the use of diagnostic tests for assessing tonsils and adenoids (e.g. airway films, sleep studies, nasal endoscopy).

Be able on physical examination to assess obstruction by tonsils, adenoids, turbinates and nasal septum.

Describe how to identify a submucous cleft palate.

Be able to counsel parents about the pathophysiology of conditions associated with tonsillar and adenoidal hypertrophy, tonsillitis and adenoiditis.

Understand the indications for tonsillectomy and/or adenoidectomy and alternative therapies.

Be able to counsel parents about the risks and benefits of tonsillectomy and/or adenoidectomy.

Know the perioperative management and expected postoperative course of patients who undergo tonsillectomy and adenoidectomy.

Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Patient Care Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Patient Care Medical Knowledge

Be able to safely and efficiently perform an adenoidectomy using the following techniques: microdebrider, coblation, curette.

Patient Care

Be able to safely and efficiently perform a tonsillectomy using the following techniques: cold snare, electrocautery, microdebrider, coblation.

Patient Care

Be able to discuss the treatment of and provide care to patients with complications of a T&A procedure.

Patient Care Interpersonal and Communication Skills

Goal 3. Ears. Be able to evaluate and treat ear disease in children.

Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the ear and eustachian tube.

Be able to take a history related to the ears and hearing.

Know how to perform microscopic otoscopy and pneumatic otoscopy.

Understand the available treatments for acute otitis media and chronic serous otitis media.

Be able to discuss the indications, risks, benefits and alternatives to tympanostomy tube placement.

ACGME Competency Goals Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills 64

Be able to counsel parents about the risks and benefits of tympanostomy tube placement.

Be able to safely and efficiently place tympanostomy tubes.

Be able to discuss and treat complications from tympanostomy tube placement.

Counsel patients and families about preventing noise exposure and hearing loss in the well child/adolescent setting (e.g. avoiding music and sounds that lead to high frequency hearing loss, wearing ear protectors for noisy tasks.)

Goal 4. Airway. Be able to evaluate children with breathing problems.

Resident Objectives: Be able to obtain an appropriate airway history.

Be able to recognize, describe and categorize stridor in children.

Know the most common causes of stridor in children.

Be able to perform and interpret flexible laryngoscopy in a child.

Know the most common cause of stridor and weak voice in a child who has undergone cardiac surgery, and the procedures associated.

Be able to assemble the equipment needed to perform a laryngoscopy, bronchoscopy and esophagoscopy.

Begin to know how to perform a direct laryngoscopy and bronchoscopy in a child.

Discuss routine care of a tracheostomy and describe how to recognize tracheostomy obstruction or decannulation.

Understand and be able to describe to parents the risks of a tracheotomy in a child.

Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Patient Care Patient Care Medical Knowledge Interpersonal and Communication Skills ACGME Competency Goals Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Patient Care Medical Knowledge Patient Care Patient Care Patient Care Patient Care Medical Knowledge Interpersonal and Communication Skills

Goal 5. Nose. Diagnose and manage pediatric patients with nasal problems.

Resident Objectives:

ACGME Competency Goals

Know the anatomy, physiology, and pathophysiology of the nose in children.

Be able to obtain a history related to the nose and nasal problems.

Medical Knowledge Patient Care 65

Understand the signs, symptoms and differences between chronic adenoiditis and sinusitis in children.

Understand the etiology, presentation, diagnosis and therapy of sinusitis in children with cystic fibrosis.

Understand and be able to recommend and interpret ancillary tests (e.g. plain films, CT scans) to evaluate nasal problems in children.

Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to evaluate a neonate with nasal obstruction, and understand the possible causes of neonatal nasal obstruction.

Patient Care Medical Knowledge Be able to describe and recognize complications of acute sinusitis in children.

Patient Care Medical Knowledge Identify the signs and symptoms of allergic rhinitis.

Patient Care Medical Knowledge Be able to describe and compare pharmacologic options for treatment of acute and chronic Patient Care adenoiditis, and sinusitis, and allergic and nonallergic rhinitis.

Medical Knowledge Goal 6. Pediatric Audiology. Understand the methods available to test the hearing in children, and how to interpret the tests.

Resident Objectives:

ACGME Competency Goals

Be familiar with the principal methods for screening the hearing of a newborn (automated auditory brainstem response, Otoacoustic emissions).

Describe general principles about interventions for hearing-impaired children (speech training, sign language, amplification devices, communication boards, cochlear implants).

Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Goal 7. Neck. Be able to diagnose and treat common problems which occur in the neck in children.

Resident Objectives:

ACGME Competency Goals

Know the age-appropriate way to behaviorally test the hearing of infants and children.

Be able to interpret routine tympanograms and audiograms.

Patient Care 66

Be able to describe the natural history, clinical presentation, evaluation and treatment options of neck abscesses (retropharyngeal, peritonsillar, parapharyngeal & lymph node) in children.

Know the symptoms, signs, and physical examination findings of a thyroglossal duct cyst and branchial cleft cyst.

Understand the differential diagnosis of Vascular anomalies in the head and neck in children, just as infantile hemangiomas, lymphatic malformations, and venous malformations.

Goal 8. General Pediatric Otolaryngology

Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Resident Objectives:

ACGME Competency Goals

Be able to obtain an appropriate history regarding possible foreign body ingestion.

Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge

Be able to describe and recognize the signs of symptoms of ear, nose, larynx, esophageal and bronchial foreign bodies.

Be able to describe the risks and benefits of foreign body removal from the head and neck.

Patient Care Medical Knowledge Interpersonal and Communication Skills

Be able to describe the signs and symptoms of ankyloglossia and the indication for frenotomy.

Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care

Be able to counsel patients about the indications, risks, benefits and alternatives to frenotomy.

Be able to safely and efficiently perform a frenotomy.

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Continue to participate in the quality improvement process and to follow-up postoperative patients whenever possible.

Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement 67

Systems-Based Practice Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Develop an understanding of OHNS coding and compliance issues in pediatric otolaryngology.

Professionalism Practice-Based Learning and Improvement Professionalism Systems-Based Practice

Goals and Objectives PGY 4: PEDIATRIC Otolaryngology Competency-based Goals and Objectives Goal 1. Be able to provide a thorough evaluation and create a treatment plan for consult and otolaryngology patients in a pediatric hospital.

Resident Objectives: ACGME Competency Goals Will provide back-up to the R2 resident for all inpatient and emergency room consults. If Patient Care R2 resident is not available will be initial contact person for all consults. R4 to work with Medical Knowledge the R2 in seeing the consults and providing guidance re a treatment plan. In conjunction Interpersonal and Communication Skills with the R2 the R4 will communicate with the fellow and attending physician re the Professionalism consult.

Systems-Based Practice Will lead twice-daily rounds on all inpatients on the otolaryngology service and at least Patient Care once-daily rounds on all consult patients. Will work together with pediatric OHNS fellow and attending faculty to provide optimum care.

Will work to educate the R2 resident and medical students re patient problems. (For example, discussing the details of care with them on morning rounds and encouraging them to read about pertinent patient issues.)

Will aid the R2 in performing a literature search to learn more about unusual patient problems.

Interpersonal and Communication Skills Systems-Based Practice Medical Knowledge Medical Knowledge Practice-Based Learning and Improvement

Attend at least one “care conference”

Systems-Based Practice 68

Goal 2. Be able to evaluate pediatric patients in the clinic with a wide range of problems.

Resident Objectives:

ACGME Competency Goals

Be able to take a history from more complicated pediatric patients such as those with multiple congenital anomalies and more complex otolaryngology problems such as those with airway obstruction, tracheostomy dependent, veloopharyngeal insufficiency, sensorineural hearing loss.

Know the features of common sequences and syndromes seen in pediatric otolaryngology patients such as: Down syndrome, velocardiofacial syndrome, oculoauriculovertebral syndrome, Treacher-Collins syndrome, Crouzon syndrome, Pierre Robin sequence, Usher’s syndrome, Pendred syndrome.

Know the common genetic abnormalities found in children with sensorineural hearing loss.

Know how to order these tests and interpret them.

Medical Knowledge

Be adept in performing nasal endoscopy and flexible laryngoscopy in neonates.

Patient Care Medical Knowledge

Be able to initiate an evaluation of a child with hypernasality. Understand the importance of coordinating care with a speech pathologist knowledgeable about velopharyngeal insufficiency.

Know the surgical and non-surgical options for treatment of velopharyngeal insufficiency.

Be able to assist with VPI procedures and to understand the perioperative course.

Patient Care Medical Knowledge Systems-Based Practice Patient Care

Know the options for treatment of different vascular anomalies, including surgical and medical management options.

Goal 3. Ears. Be able to evaluate and treat ear disease in children.

Resident Objectives: Know the common presenting symptoms and findings in pediatric patients with a tympanic membrane perforation, severe atelectasis, cholesteatoma, microtia and sensorineural hearing loss.

Be able to formulate appropriate treatment plans for all patients with the above clinical conditions.

Know the indications for aural habilitation (and rehabilitation) in children with hearing loss. Understand the types of hearing aids available and the difficulties in treating children with these devices.

Medical Knowledge

Medical Knowledge Patient Care Systems-Based Practice

Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Medical Knowledge Patient Care Patient Care Interpersonal and Communication Skills Medical Knowledge

69

Understand the indications for bone-anchored hearing aids and cochlear implants in children.

Be able to counsel families of children with ear disease regarding appropriate surgical and non-surgical management of their child’s condition.

Be able to perform an underlay tympanoplasty, and simple Mastoidectomy. Be able to assist with canal atresia reconstruction. Understand the expected perioperative course and potential complications of these procedures.

Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Medical Knowledge Patient Care Medical Knowledge

Understand the treatment options and treatment timeline for microtia and canal atresia. Be able to assist in rib cartilage harvest and auricular reconstruction.

Goal 4. Be able to evaluate and treat children with breathing problems.

Resident Objectives:

Patient Care Medical Knowledge

Know the common causes and treatments for children who present with a complaint of chronic throat clearing and/or cough. Be able to counsel families regarding these treatments.

Be able to formulate a treatment recommendation for children with airway obstruction including children with laryngomalacia, subglottic stenosis, tracheal stenosis, laryngeal cleft, subglottic hemangioma, subglottic cysts.

Know the indications, risks and benefits for the following procedures including; microdirect laryngoscopy with excision of lesion, supraglottoplasty, laryngotracheal reconstruction, slide tracheoplasty. Be able to counsel patients regarding these procedures.

Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge

Be able to discuss the post-operative care for the patient who has undergone a Laryngotracheal reconstruction.

Know the most common causes of acute onset of stridor and how to treat them (eg croup, supraglottitis, foreign body aspiration, deep neck abscess.)

Know the etiology of perioperative laryngospasm in children and how to treat it.

Know the etiology, typical patient, and treatment options for vocal fold dysfunction syndrome (paradoxical vocal fold motion).

Goal 5. Diagnose and manage pediatric patients with nasal problems.

Resident Objectives: Know the presenting symptoms of a child with choanal atresia, nasal dermoid, nasal glioma, nasal encephalocele.

ACGME Competency Goals

Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Patient Care Medical Knowledge 70

Know the different options for repair of choanal atresia and understand the indications, timing, risks and benefits of repair.

Understand the causes of chronic sinusitis in children and the indications for endoscopic sinus surgery. Be able to discuss with families the expected perioperative treatment course.

Be able to perform endoscopic sunus surgery under direct supervision.

Be able to set up and utilize the surgical navigation system in the operating room.

Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Systems-Based Practice Goal 6. Neck. Be able to diagnose and treat common problems which occur in the neck in children.

Resident Objectives: Be able to describe the natural history, clinical presentation, evaluation and treatment options of different types of vascular malformations.

Know the presentation, work-up, and treatment for congenital torticollis (fibromatosis colli) in young children.

Be able to formulate a differential diagnosis for any type of neck mass in a child.

Goal 7. General Pediatric Otolaryngology Resident Objectives: Be able to perform a microdirect laryngoscopy, and bronchoscopy in a neonate. Be able to perform a routine bronchoscopy with foreign body removal, and esophagoscopy with foreign body removal.

Continue to develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Continue to develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

ACGME Competency Goals Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Patient Care Interpersonal and Communication Skills Professionalism Systems-Based Practice Professionalism

Continue to participate in the quality improvement process and to follow-up postoperative patients whenever possible.

Practice-Based Learning and Improvement Professionalism

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Continue to develop an understanding of OHNS coding and compliance issues in pediatric otolaryngology.

Professionalism Practice-Based Learning and Improvement Professionalism Systems-Based Practice 71

HALF-TIME RESEARCH RESIDENT • Research Resident must have at least 2.5 days of research time per week on average.

• During PGY2 or PGY4’s vacation/conference/interview period, Half-time Research Resident usually works as full time.

72

Veteran’s Administration Palo Alto Rotation Contacts and Scheduling Details Rotation Director: Davud Sirjani, MD, dsirjani@stanford.edu, 314-537-0242 (cell) Attendings who need Resident clinic coverage: Baik, Nayak, Sajjadi, Sirjani, Sung Private Attendings- residents do not cover: Makarewycz Fellows- do not need Resident clinic coverage: Facial-Plastics – Sarah Akkina Important Contacts: Main # 650-493-5000 (dial 1→1→ ext#) Administrators: ENT Admin. email: v21palentadminpaloalto@va.gov Erik Nielsen: ext. 63202, erik.nielsen1@va.gov Maria Tham: ext. 66912, Maria.Tham@va.gov Surgical Onboarding Team: vhapalsuronboarding@va.gov Charge Nurse: Ella Benadam-Lenrow: ext 64047 Ella.Benadam-Lenrow@va.gov

RNP: Annie Yuan: 65203 Annie.Yuan@va.govAnnie.Yuan@va.gov

LVN: Crystal Vo: ext 64046 Crystal.Vo@va.gov Additional Required Conferences ▪ Wednesday (every other week) at the Radiology Conference Room (Building 102) from 8:30-9:30 am

PA-C: Leslie Chan: ext. 65535 Leslie.Chan@va.gov Clinic rules ▪ Clinic starts promptly at 9 am and 1pm ▪ Please complete inpatient rounds and workload prior to start of clinic

73

Weekly Schedule Time AM 0800-1200

Monday- 8:30am Minor Proc: PGY 3>5 Baik Clinic: PGY 5>3, NP

NON-OPERATIVE WEEK (starting 7/1/21) Tuesday- 8:30am Wednesday- 8:00am Sirjani Clinic: PGY 3, 5, COCLIA NP (8:00 – 9:00 am) Nayak Clinic (9:00): PGY 3, 5, PA

FP clinic PM 1200-1700

Baik Clinic: PGY 3,5, NP

Sirjani Clinic: PGY 3, 5, NP, R

Nayak Clinic: PGY 3, 5, R, PA

Time AM 0800-1200

Monday -8am OR- FP: PGY 3, 5

Friday- 7am **OR- Baik/Sirjani PGY3,5

Sung Minor Procedures: PGY 3 or 5, PA

RNP clinic (AY)

OR- Sung PGY 3 or 5

**OR- Baik/Sirjani PGY 3, 5

Sajjadi Clinic: PGY 3 or 5, R, PA

FP Clinic R: Research Resident

Thursday- 7am **OR- Sajjadi: PGY 3 or 5

**1 resident to scrub out for pre-ops OPERATIVE WEEK (starting 7/8/21) Tuesday- 8:30am Wednesday- 7am Sirjani Clinic: Tumor Board (8:30PGY 3, 5, NP 9:30am)

Thursday- 7am **OR- Sajjadi: PGY 3 or 5

Baik Clinic: NP

RNP clinic (AY) OR- Nayak: PGY 3, 5

PM 1200-1700

OR- FP: PGY 3 or 5 Baik Clinic: PGY 3 or 5, NP

Friday- 7am **2 ORs- Baik/Sirjani

Sirjani Clinic: PGY 3, 5, R, NP

0900 Sung Clinic: R, PA

Sung Clinic/Minor Procedures: PGY 3 or 5, PA

OR- Nayak PGY 3, 5

OR- Sung PGY 3 of 5

Sung Clinic: R, PA

Sajjadi Clinic- JS, PGY3 or 5, R, PA

**2 ORs- Baik/Sirjani

**1 resident to scrub out for pre-op clinic appointments** Additional Notes: • Monday OPERATIVE WEEK: check-in patient at 8AM, case starts at 9AM • All other OPERATIVE WEEK: check-in patient in at 7AM, case starts at 8AM 74

•

ALL PATIENTS: Surgical site MUST be marked, even bilateral or midline cases need a wrist band stating the procedure to be done.

RESEARCH RESIDENT (R: RESEARCH RESIDENT) • If clinic needs extra-help from Research resident please give those dates in advance.

• Research Resident must have at least 2.5 days of research time per week on average.

• During PGY3 or PGY5’s vacation/conference/interview period, Research resident usually works as full time.

• Check to see if help is needed for Monday procedures in Baik clinic the week before.

Non-Operative Week Wednesdays: COCLIA • COCLIA is the Comprehensive Otolaryngologic Curriculum Learning through Interactive Approach provided by the American Academy of Otolaryngology – Head & Neck Surgery Foundation. It can be found at: https://www.coclia.org.

• The VA residents and all residents on full-time or ½-time research will participate in the bi-weekly COCLIA session.

• The VA PGY5 will pick a topic from the curriculum and assign questions for each resident cover.

• Each resident will provide a handout summarizing the answers to their assigned questions.

• Research residents may participate via Zoom if they are not scheduled to be at the VA that day.

Rotation Specifics See APPENDIX Q (VAPAHCS ENT Resident Handbook) for comprehensive details.

Evaluation and Feedback The VAPAHCS faculty and selected ancillary medical personnel will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

75

Goals and Objectives PGY 3: VAPA Competency-based Goals and Objectives Goal 1. Expand knowledge in area of head and neck oncology.

Resident Objectives: Be able to accurately stage cancers of the head and neck.

Develop an understanding of the role of chemotherapy and radiation therapy in the treatment of head and neck cancer.

Begin to be able to formulate a treatment plan for head and neck tumors with supervision, and be able to effectively counsel patients regarding treatment options including risks associated with surgical treatment.

Progress in ability to counsel patients regarding head and neck cancer risk factors.

Be able to work-up and treat patients with thyroid and parathyroid diseases.

Be able to work-up and treat patients with salivary gland tumors.

Be able to recognize the histopathologic appearance of common head and neck neoplasms, including parotid and thyroid pathology.

Goal 2. Expand knowledge of common otologic complaints.

Resident Objectives: Be able to outline the assessment, work-up, and management of sudden sensorineural hearing loss.

Progress in the ability to systematically evaluate the dizzy patient.

Be able to formulate operative and non-operative treatment plans for patients with chronic otitis media.

Demonstrate facility with counseling patients regarding the expected risks and benefits associated with surgery for chronic ear disease.

ACGME Competency Goals Medical Knowledge Medical Knowledge Patient Care Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement 76

Be able to describe the pathophysiology of cholesteatoma.

Medical Knowledge

Develop the ability to recommend ‘for’ or ‘against’ hearing amplification based on audiometric considerations, and be able to effectively advise patients regarding appropriate amplification options.

Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement

Goal 3. Expand knowledge of common rhinologic disorders.

Resident Objectives:

ACGME Competency Goals

Progress in the ability to evaluate and treat patients with epistaxis, including non-operative and operative management as well as counseling patients regarding risk reduction.

Patient Care Medical Knowledge Practice-Based Learning and Improvement

Be able to successfully evaluate patients with chronic sinusitis, and be able to counsel patients regarding medical and surgical treatment options.

Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement

Demonstrate increasing facility and diagnostic skill with rigid nasal endoscopy.

Patient Care

Progress in the ability to successfully interpret sinus imaging studies.

Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement

Be able to competently counsel patients regarding the risks associated with sinonasal surgery.

Goal 4. Expand knowledge of voice and swallowing disorders Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the larynx.

ACGME Competency Goals Medical Knowledge

Take a history with focused questions that assist in the diagnosis of hoarseness and dysphagia.

Be able to subjectively assess and describe hoarseness (i.e. GRBAS scale)

Patient Care Patient Care Medical Knowledge 77

Describe the use of diagnostic tests for assessing hoarseness (e.g. CT scans, laryngeal endoscopy, stroboscopy).

Be able on physical examination to assess dysfunction of vocal folds (i.e. paralysis).

Patient Care Medical Knowledge Patient Care

Be able to counsel parents about the pathophysiology of conditions associated with vocal fold paralysis.

Patient Care

Understand the indications for vocal fold medialization (e.g. injection, thyroplasty, arytenoid repositioning) and alternative therapies.

Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills

Be able to counsel parents about the risks and benefits of vocal fold medialization.

Interpersonal and Communication Skills

Be able to safely and efficiently perform a flexible fiberoptic nasolaryngoscopy and stroboscopy.

Be familiar with the principal lesions that can affect vocal fold function in adults (i.e. papilloma, polyp, nodule, cyst, cancer).

Patient Care

Be able to identify the various methods for laryngeal framework surgery (e.g. thyroplasty, arytenoid adduction); their indications and their possible complications.

Patient Care Medical Knowledge Patient Care Medical Knowledge

Know the instrumentation used to resect laryngeal lesions (i.e. endoscopic scissors, graspers, lasers).

Patient Care Medical Knowledge

Understand the available radiographic and endoscopic methods of assessing swallowing.

Goal 5. Increase knowledge of sleep medicine.

Resident Objectives:

Patient Care

Increase competence in the assessment of patients with suspected sleep apnea.

Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement

Progress in the ability to interpret polysomnographic data in adults.

Be able to effectively counsel patients regarding the consequences of untreated sleep apnea, and regarding appropriate treatment options.

ACGME Competency Goals

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Goal 6. Increase knowledge in the area of facial trauma and reconstruction.

Resident Objectives: Be able to perform a thorough physical examination in the facial trauma and reconstruction patient with a command of positive signs to be sought and their significance.

Be able to effectively counsel facial trauma and reconstruction patients regarding treatment options, potential complications, and expected post-operative course.

Goal 7. Expand knowledge of head and neck infectious disorders.

Resident Objectives: Be able to successfully evaluate and recognize cases of deep neck infection, and be able to outline an appropriate treatment plan.

Be able to describe the pathophysiology of necrotizing fasciitis, and the treatment of this disorder.

Demonstrate an understanding of the clinical presentation of mycobacterial infection in the head and neck, including organisms involved and appropriate management.

Be able to describe the stages of orbital infection in complicated sinusitis, and outline appropriate treatment options.

Goal 8. Expand ability to perform surgical procedures Resident Objectives: Be able to competently and efficiently perform mid-level procedures with attending assistance such as: o Laryngology Microlaryngeal excision of papillomas, polyps, leukoplakia Injection laryngoplasty o Otology/Neurotology Tympanoplasty Straightforward simple mastoidectomy o Head and Neck Submandibular gland excision Excision of congenital cysts Resection of small carcinomas (e.g. tongue, floor of mouth) Uvulopalatopharyngoplasty

ACGME Competency Goals Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Practice-Based Learning and Improvement ACGME Competency Goals Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Patient Care

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o Rhinology Septoplasty Turbinate reduction Selected endoscopic sinus surgery (concha bullosa, polypectomy, partial ethmoidectomy, maxillary antrostomy) o Facial Plastic and Reconstructive Surgery Closed nasal reduction Open nasal reduction (straightforward) Closure of complex facial lacerations Local flaps Goal 9. General knowledge Resident Objectives: Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds

ACGME Competency Goals Patient Care Medical Knowledge

Gain an understanding of the set-up and use of the image-guidance system.

Learn to set-up and use the facial nerve integrity monitor.

Demonstrate competence in the safe and appropriate use of various lasers.

Patient Care Patient Care Patient Care

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Patient Care Systems-Based Practice Patient Care Systems-Based Practice

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement

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Goals and Objectives PGY 4/5: VAPA Competency-based Goals and Objectives Goal 1. Know how to care for the otolaryngology patient.

Resident Objectives: The R4/5 will be able to efficiently execute the evaluation of most patients without major changes being suggested by supervising faculty.

Demonstrate a command of relevant literature and be able to apply it in the development of an evaluation and (surgical and/or non-surgical) treatment plan for the full spectrum of OTO/HNS problems such as: o Head and neck malignancy

o Complicated sinonasal disease

o Complex facial reconstruction o Complex oto-neurotologic complaints o Advanced voice and swallowing disorders o Obstructive sleep apnea Demonstrate confidence and competence in the management of OTO/HNS emergencies.

ACGME Competency Goals Patient Care Medical Knowledge

Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge Practice-Based Learning and Improvement Patient Care Medical Knowledge

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Exhibit leadership and clear thinking while efficiently mobilizing appropriate resources to care for such problems as airway emergencies, hemorrhage, and OTO/HNS trauma.

Demonstrate the ability to think ahead and contingency plan to avoid errors caused by lack of equipment, lack of staff, or lack of appropriate attending or specialty back-up.

Demonstrate proficiency in the recognition and management of surgical risk factors.

Patient Care Medical Knowledge Systems-Based Practice Systems-Based Practice Patient Care Medical Knowledge

Demonstrate proficiency in the recognition, management, and avoidance of surgical complications.

Patient Care

Be able to successfully transition from supervision by faculty to primary decision making with faculty oversight.

Patient Care

Supervise presentation of complications on the service at monthly Quality Assurance conference.

Practice-Based Learning and Improvement

Demonstrate competence and organizational skills in directing the resident team in the daily management of in-house patients and OR activities.

Patient Care

Demonstrate ability and commitment in the day-to-day informal teaching and mentoring of students and junior residents.

Practice-Based Learning and Improvement

Be able to competently supervise/assist junior residents performing common OTO/HNS surgical procedures.

Practice-Based Learning and Improvement

Be able to demonstrate excellent interpersonal skills, effectively setting the tone for other members of the resident team, clinical and non-clinical staff.

Interpersonal and Communication Skills

Goal 2. Be able to perform standard otolaryngology procedures.

Resident Objectives:

Medical Knowledge

Medical Knowledge

Medical Knowledge

ACGME Competency Goals

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Be able to competently and efficiently perform advanced otolaryngology procedures such as: o Otology/Neurotology Tympanomastoidectomy Ossicular chain reconstruction Stapedotomy o Head and Neck Maxillectomy Partial laryngeal surgery Composite resection Total parotidectomy with nerve grafting Surgical management of aggressive thyroid malignancy o Rhinology Revision endoscopic sinus surgery Orbital decompression Repair of CSF leaks o Laryngology Microlaryngeal excision of cancer with laser and cysts with microflap technique Endoscopic and open cricopharyngeaus and Zenker’s diverticulum surgery Thyroplasty and arytenoid repositioning surgery In office injection larygoplasty, laser surgery, and trans-nasal esophagoscopy o General Advanced techniques in obstructive sleep apnea surgery o Facial Plastic and Reconstructive Surgery Complex facial trauma, such as Le Fort fractures, naso-orbital-ethmoid fractures, and comminuted mandible and midface fractures Functional rhinoplasty Repair of post-traumatic and post-ablative defects

Patient Care

Skin resurfacing for malignancy prophylaxis

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Goal 3. Have a comprehensive otolaryngology knowledge base.

Resident Objectives: Develop competence in the interpretation of head and neck imaging studies through regular review of all patient imaging and attendance at radiology rounds.

ACGME Competency Goals Patient Care Medical Knowledge

Learn the nuances of correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Patient Care Systems-Based Practice Patient Care Systems-Based Practice

Be able to appropriately document patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of healthcare.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement

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Stanford Health Care: Specialties Team (Scope) Rotation Contacts and Scheduling Details Rotation Directors: Otology/Neurology Nikolas Blevins, M.D. nblevins@stanford.edu

Rhinology Peter Hwang, MD hwangph@stanford.edu

Facial Plastics Sam Most, MD smost@stanford.edu

Attendings: Alyono, Blevins, Hwang, Jackler, Most, Nayak, Patel, Pepper, Santa Maria, Stankovic, Steenerson Weekly Schedule Monday

Tuesday

Wednesday

Thursday

AM

Blevins OR Most OR Hwang clinic Santa Maria OR Pepper OR (1st/3rd Mondays) Alyono clinic

Hwang OR Most clinic Jackler clinic Capasso clinic (RWC) Alyono clinic

Most MRP Jackler OR Blevins clinic Hwang clinic Pepper clinic Alyono clinic

Blevins OR Hwang OR Jackler OR Nayak clinic Santa Maria clinic FP fellow clinic

PM

Blevins OR Most OR Hwang clinic Pepper OR (1st/3rd Mondays) Alyono clinic

Hwang OR Jackler clinic Capasso clinic (RWC) Most clinic Alyono clinic

Most MRP Jackler OR Blevins clinic Hwang clinic Pepper clinic Alyono clinic

Blevins OR Hwang OR Jackler OR Nayak clinic Most clinic

Friday Nayak OR Most OR Pepper OR Allergy clinic Blevins clinic Otology fellow clinic Alyono OR Nayak OR Most OR Pepper OR Blevins clinic Otology fellow clinic Rhinology fellow clinic Jane Wang clinic Alyono OR

NOTE: Every resident is expected to attend: o 1 Cochlear Implant conference each rotation (7:30-8:30 am the 2nd and 4th Wednesdays of the month). o 1 Stanford Balance Center conference each rotation (7am – 8 am), typically the 3rd Tuesday of the month.

Rotation Specifics 1. The team is expected to round together on all patients. “Splitting” the team to cover rounds on different patients is not acceptable.

Rounds should occur two times daily.

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2. During the week a resident should have a conversation with each attending re his/her patients. On the weekend some kind of formal notification (phone, text, etc) is expected daily.

3. All phone calls/patient contacts should be entered into EPIC. Contact attending directly if needed.

4. The R2 resident is the initial contact person for all consults. All consults should be seen by an attending- presented the same day and signed off by the next day. Discuss the consult list on rounds daily.

5. There should be a culture of teaching at all levels.

6. Chiefs can assign appropriate coverage of OR’s. When OR is complete residents should go to clinic. “Key indicator cases” should take precedence. Residents should see post-op cases in the clinic whenever possible.

7. Residents need to go to scheduled educational sessions and should break out of cases as needed. On time attendance is expected except for emergencies.

8. Residents are expected to read about cases in advance and check on important clinical info (CT, MRI, Audio, Path etc).

9. When faculty are out of town residents should extend coverage to other clinics/OR’s which are usually uncovered. Chiefs can make assignment for otherwise unassigned time.

Evaluation and Feedback The faculty, and selected ancillary medical personnel will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

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Goals and Objectives PGY 1: SHC Specialty Service Competency-based Goals and Objectives Goal 1. OHNS specialty service inpatients. Learn about the most common surgeries and disorders requiring admission to the hospital.

Resident Objectives: ACGME Competency Goals Round with the inpatient team 2x daily. Learn the most common surgeries and OHNS disorders requiring admission to the hospital. Understand the expected hospital course and requirements for discharge.

Become familiar with the Stanford EMR (EPIC) and how to input orders.

Begin to develop surgical skills in the following areas: Facial Plastics service: suturing/soft tissue handling, squire knot-tying, patient positioning, identify of common surgical instruments and handling techniques.

Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge

Sinus/rhinology: Inferior turbinate reduction, zero-degree rigid nasal endoscopy, office balloon sinuplasty, office polypectomy, allergy clinic (shot skills and interpretations- at least 6 visits) Otology: in-clinic binocular microscopy, cerumen removal, mastoid bowl cleaning, basic audiologic testing and interpretations.

Perform a literature search to learn more about unusual patient problems.

Medical Knowledge Practice-Based Learning and Improvement

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice

Utilize translation services to communicate with non-English speaking patients as needed.

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Demonstrate effective time-management skills.

Practice-Based Learning and Improvement

Goals and Objectives PGY 2/3: SHC Specialty Service Competency-based Goals and Objectives Goal 1. Consults in an adult hospital. Learn about the most common consults requested from other medical and surgical services regarding otolaryngology problems.

Resident Objectives: ACGME Competency Goals Be the initial contact person for all consults from other SHC services and the emergency department.

Perform initial evaluation of all consult patients.

Evaluate consult patients with senior resident or fellow and faculty member and communicate recommendations and plan to primary team. Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems.

Create a complete and coherent consultation note and dictate it in a timely fashion. This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice Patient Care Medical Knowledge Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice

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Demonstrate effective time-management skills.

Practice-Based Learning and Improvement

Follow-up on consult patients as needed.

Patient Care Systems-Based Practice Professionalism

Goal 2. Nasal cavity and sinuses. Diagnose and manage patients with nasal problems.

Resident Objectives: Be familiar with the EMR at Stanford (EPIC) to confidentially access appropriate patient information, past culture results, pathology reports and past imaging studies.

Evaluate consult patients with sinonasal disorders with the senior residents and faculty. Be able to document and communicate recommendations and plan with the primary team in a professional and courteous manner.

Know the anatomy, pathophysiology, and development of the nasal cavity and sinuses.

Perform literature searches to investigate common and rare patient presentations, and to obtain evidence for current practice paradigms in patient care.

Understand principles and utility of CT versus MRI imaging of the sinuses. Understand and describe anatomic variations of the 4 pairs of paranasal sinuses, patterns of uncinate process attachment and sinus drainage patterns.

Be able to obtain a detailed history related to the nose and nasal problems related to sinus disease and allergic rhinitis.

Perform safe, informative routine office nasal endoscopy with 0 degree and 30 degree rigid endoscopes.

Access and understand AAO descriptive guidelines for acute, subacute and chronic sinusitis, and know the major and minor symptoms associated with diagnosis of sinusitis.

ACGME Competency Goals Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge Medical Knowledge Practice-Based Learning and Improvement Professionalism Medical Knowledge Interpersonal and Communication Skills Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Systems-Based Practice

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Evaluate patients with chronic sinusitis with and without polyposis – and distinguish which patients may require surgery or medical therapy.

Be able to describe and recognize complications of acute sinusitis.

Identify the signs and symptoms and differences between allergic rhinitis and acute/chronic sinusitis.

Understand indications for safe intranasal office biopsy.

Be proficient with the evaluation and management algorithms for treating epistaxis.

Understand options for treatment of nasal septal deviation and turbinate hypertrophy.

Learn the assembly of equipment needed to perform nasal endoscopy, and intraoperative image guidance.

Patient Care Medical Knowledge Professionalism Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

Complete basic aspects of endoscopic approaches to the nasal cavity – including use of zeroPatient Care degree and 30 degree endoscopes, safely navigating the nasal cavity with mucosal preserving Medical Knowledge technique, performing septoplasty, turbinate reduction, maxillary antrostomy, and anterior ethmoidectomy.

Goal 3. Allergy – Contact Dr. Meng Chen (mengchen@stanford.edu) at least one month prior to your visit.

Resident Objectives: ACGME Competency Goals Proper history/evaluation and assessment of the allergy patient Patient Care Medical Knowledge Knowledge of therapies for the general allergy patient, including medication classes, dosages, side effects, and combination therapies Proper administration of a skin-prick test x 1

Patient Care Medical Knowledge Patient Care

Proper interpretation of a skin prick test, and historic end point titration test interpretation

Medical Knowledge

90

Proper design of an immunotherapy strategy based on prick testing (Each resident will receive instruction in immunotherapy design from the allergy team).

Medical Knowledge Patient Care

Understanding the goals, principles and practice of ASA desensitization therapy, and how AERD/ASA intolerance differs from classic allergic reactions.

Medical Knowledge

Advantages/disadvantages/principles of intradermal vs. sublingual immunotherapy

Medical Knowledge

Goal 4. Understand the basics of the aesthetic patient consultation Resident Objectives:

ACGME Competency Goals

Perform initial contact with outpatient facial plastics patient consultation.

Patient Care

Understand pathophysiology of aging process.

Medical Knowledge

Goal 5. Understand the approach to the rhinoplasty patient Resident Objectives: Perform initial contact with outpatient consultation for nasal obstruction and/or aesthetic rhinoplasty.

Understand pathophysiology of nasal obstruction.

Goal 6. Understand the approach to the facial trauma patient Resident Objectives: Provide effective specialist consult services to trauma team/ED for facial trauma.

Understand wound healing.

Understand concepts of occlusion.

Evaluate patients with facial paralysis.

Understand pathophysiology of facial paralysis.

ACGME Competency Goals Patient Care Medical Knowledge ACGME Competency Goals Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Medical Knowledge Medical Knowledge Patient Care Medical Knowledge Medical Knowledge

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Goal 7. Chronic Otitis Media. Screen, diagnose and manage patients with symptoms secondary to their chronic ear infections Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the middle ear and mastoid.

Take a directed history focused on issues related to recurrent and chronic ear infections.

ACGME Competency Goals Medical Knowledge

Describe the use of diagnostic tests for assessing otologic disease (e.g. CT and MRI imaging, audiology, tympanometry).

Patient Care Medical Knowledge

Be able to assess the external and middle ear on exam, including the use of the binocular microscope.

Differentiate middle ear from external ear disease Be able to counsel parents about the pathophysiology of conditions associated with chronic otitis, its risks, and treatment options.

Understand the indications for surgical intervention, its risks and potential complications

Patient Care

Be able to counsel parents about the risks and benefits of tympanomastoid surgery.

Know the perioperative management and expected postoperative course of patients who undergo tympanomastoid surgery.

Patient Care

Patient Care Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Patient Care

Be able to safely and efficiently perform the approach for tympanomastoid surgery (postauricular incisions, canal incisions, harvesting graft materials).

Be comfortable with mastoidectomy techniques ( bony landmarks, use of drill for cortical bone removal, effective use Suction-irrigation system).

Patient Care

Be able to discuss the basics of tympanomastoid surgery patients including potential complications and postoperative expectations.

Patient Care Interpersonal and Communication Skills

Goal 8. Vertigo. Be able to evaluate and treat peripheral vestibular disease.

Resident Objectives:

ACGME Competency Goals

Patient Care

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Be able to describe the anatomy, physiology, and pathophysiology of the peripheral vestibular system.

Be able to take a history related to balance and vertigo.

Know how to perform clinical examination of patients with vestibular complaints.

Understand treatments available for acute vestibular dysfunction in the clinic and emergency room.

Be able to discuss factors involved in vertigo and balance dysfunction with patients and families.

Be able to counsel parents about the various treatment options available for management of Meniere’s disease, paroxysmal positioning vertigo, and vestibular neuronitis, superior semicircular canal dehiscence, etc Be able to interpret the basics of vestibular function tests.

Be able to discuss care of vertigo patients with providers from other specialties to formulate a care plan involving a number of disciplines.

Counsel patients and families about compensatory strategies for minimizing risks in chronic vestibulopathy including the role of vestibular rehabilitation and physical therapy.

Goal 9. Hearing Loss Resident Objectives: Be able to obtain an appropriate hearing loss history.

Be able to recognize, describe and categorize acquired and congenital hearing loss.

Know the most common causes of sensorineural vs conductive hearing loss.

Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Interpersonal and Communication Skills ACGME Competency Goals Patient Care Patient Care Medical Knowledge Patient Care Medical Knowledge

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Be able to perform and interpret appropriate physical examination for hearing loss, including tuning fork exam, otomicroscopy, cranial nerve exam, pneumo-otoscopy.

Patient Care

Understand the basics of audiometry, and how to interpret common audiometric tests.

Patient Care Medical Knowledge

Be able to counsel patients about hearing aids and assistive listening devices.

Patient Care Medical Knowledge Patient Care

Understand the basic options involved in the surgical correction of conductive hearing loss (stapedectomy, ossiculoplasty).

Gain basic capacity for evaluating ossicular chain mobility intraoperatively, and gain a foundation for bimanual manipulation of prostheses under the surgical microscope.

Patient Care

Be able to discuss the basics of cochlear implantation with patients and families, including the basics of surgery, postoperative expectations, and need for rehabilitation services.

Patient Care Medical Knowledge Interpersonal and Communication Skills

Goal 10. Neurotology. Diagnose and manage patients with skull base disease Resident Objectives: Know the basic anatomy, physiology, and pathophysiology of the skull base.

Be able to obtain a history related to extra-axial neoplasms and other lesions of the internal auditory canal, cerebello-pontine angle, temporal bone and posterior fossa.

Understand the basic anatomy, signs, symptoms and clinical diagnosis of lesions of the petrous apex.

Understand the basics of radiologic studies used to diagnose lesions of the posterolateral skull base.

Understand the indications of ancillary tests (e.g. angiography, electrodiagnostic studies) to evaluate skull base lesions.

ACGME Competency Goals Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to evaluate a patient with vestibular schwannoma in the clinic, including history, physical examination, audiometric data, and radiologic studies.

Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to describe and recognize complications of cranial base surgery.

Patient Care 94

Medical Knowledge Be able to collaborate with a multidisciplinary team to provide comprehensive care for patients with skull base lesions.

Patient Care Medical Knowledge Interpersonal and Communication Skills Understand the basic management options for benign lesions of the posterio-lateral skull base Patient Care including watchful waiting, focused radiation, and microsurgical resection.

Medical Knowledge Goal 11. Audiology. Understand the methods available to test the hearing, and how to interpret the tests.

Resident Objectives:

ACGME competency goals

Be familiar with the principal methods and indications for various audiometric tests including pure-tone testing, word recognitions scores, reflex testing, tympanometry).

Patient Care Medical Knowledge Patient Care Medical Knowledge

Be familiar with the basics of assessing reliability in audiometric testing.

Be able to interpret routine tympanograms and audiograms.

Patient Care Medical Knowledge

Understand the basics of most specialized electrodiagnostic studies and their indications (including ABR, ECOG, VEMP, rotational chair, posturography testing, VNG, etc).

Patient Care Medical Knowledge

Goal 12. Facial nerve. Be able to diagnose and treat common facial nerve problems.

Resident Objectives:

ACGME competency goals

Be able to describe the basic anatomy of the facial nerve and its common disorders, including their natural history, clinical presentation, evaluation and treatment.

Patient Care Medical Knowledge

Understand the management of acute facial paralysis, especially as it applies to the postoperative patient.

Patient Care Medical Knowledge

Goal 13. General Otology Resident Objectives Be able to obtain an appropriate history regarding external ear disease, including acute and chronic otitis externa and cerumen impaction.

ACGME competency goals Patient Care Interpersonal and Communication Skills 95

Become comfortable with otoscopic examination and procedures involving the external auditory canal including canal debridement and cerumen removal.

Be able to discuss the procedure, risks, benefits, and expectations of myringotomy with aspiration, and myringotomy with tube placement.

Be able to discuss the basics of tinnitus diagnosis and management.

Be able to perform a directed history and physical examination for patients with otalgia.

Know how to obtain consultation from other related services for patients with otologic disorders.

Develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of otologic care.

Develop an understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become an intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies. Perform literature searches as needed to continuously improve the level of medical knowledge.

Develop an understanding of OHNS coding and compliance issues in otology/ neurotology.

Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement Professionalism Systems-Based Practice

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Goals and Objectives PGY 4: SHC Specialty Service Competency-based Goals and Objectives Goal 1. Consults in an adult hospital. Continue to learn about consults requested regarding otologic problems.

Resident Objectives: Be the backup or initial contact person for consults from other SHC services and the emergency department.

Perform initial or backup evaluation for consult patients.

Be familiar with the subtleties of the SHC electronic medical record (Epic) and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Evaluate consult patients with chief resident, fellow, and faculty member and communicate recommendations and plan to primary team. Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems, and teach other residents, and medical students.

Create or review a complete and coherent consultation note and dictate it in a timely fashion.

This objective applies to all patients seen in the clinic setting as well as the outpatient setting.

Utilize translation services to communicate with non-English speaking patients as needed.

ACGME Competency Goals Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice Patient Care Medical Knowledge Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice

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Demonstrate effective time-management skills.

Practice-Based Learning and Improvement

Follow-up on consult patients as needed.

Patient Care Systems-Based Practice Professionalism

Attend multidisciplinary Skull Base Tumor rounds.

Systems-Based Practice

Goal 2. Chronic Otitis Media. Screen, diagnose and manage patients with symptoms secondary to their chronic ear infections Resident Objectives: ACGME Competency Goals Be able to describe the anatomy, physiology, and pathophysiology of the middle ear and mastoid, and the variations seen that may influence optimal treatment options.

Medical Knowledge

Take a refined history focused on issues related to recurrent and chronic ear infections.

Patient Care

Describe and assess the use of diagnostic tests for assessing otologic disease (e.g. CT and MRI imaging, audiology, tympanometry). Refine efficiency in ordering tests.

Patient Care Medical Knowledge Systems-Based Practice Patient Care

Be able to assess the external and middle ear on exam, including the use of the binocular microscope and otoendoscopy. Refine the interpretation of clinical findings to formulate a treatment plan.

Differentiate middle ear from external ear disease.

Be able to counsel parents about the pathophysiology of conditions associated with chronic otitis, its risks, and treatment options.

Understand the indications for surgical intervention, its risks and potential complications.

Understand how history and anatomy influence surgical treatment planning.

Be able to counsel parents about the risks and benefits of tympanomastoid surgery, and obtain informed consent for planned procedure.

Know the perioperative management and expected postoperative course of patients who undergo tympanomastoid surgery. Be able to answer the majority of postoperative questions/ concerns.

Patient Care Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Patient Care

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Be able to safely and efficiently perform the majority of tympanomastoid surgery including mastoidectomy, transcanal procedures, ossiculoplasty, etc.

Patient Care

Refine comfort with mastoidectomy and bone removal techniques; increase safety and efficiency.

Be able to assess outcomes over time and formulate plans based on the evolution of the underlying disease.

Goal 3. Vertigo. Be able to evaluate and treat peripheral vestibular disease.

Resident Objectives: Be able to describe the anatomy, physiology, and pathophysiology of the peripheral vestibular system, and how it impacts clinical presentation.

Patient Care

Be able to take a history related to balance and vertigo. Formulate a directed and practical differential diagnosis.

Patient Care Interpersonal and Communication Skills

Know how to perform clinical examination of patients with vestibular complaints.

Differentiate peripheral from central pathology.

Patient Care

Understand treatments available for acute vestibular dysfunction in the clinic and emergency room.

Patient Care Medical Knowledge

Refine ability to discuss factors involved in vertigo and balance dysfunction with patients and families.

Patient Care Medical Knowledge Interpersonal and Communication Skills

Be able to counsel parents about the various treatment options available for management of Meniere’s disease, paroxysmal positioning vertigo, and vestibular neuronitis, superior semicircular canal dehiscence, etc. Discuss medical vs surgical approaches, and formulate an understanding of the role of surgery in these disorders.

Be able to interpret vestibular function tests, and use them in forming a treatment plan.

Patient Care Interpersonal and Communication Skills

Be able to discuss care of vertigo patients with providers from other specialties to formulate a care plan involving a number of disciplines. Understand the role of otolaryngologist and other specialists in the management of vestibular disorders.

Patient Care

ACGME Competency Goals Medical Knowledge

Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills

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Be familiar with the surgical management of peripheral vestibular disease, and be able to perform the majority of the steps necessary for their successful completion.

Patient Care Medical Knowledge Interpersonal and Communication Skills

Goal 4. Hearing Loss Resident Objectives: Be able to obtain a comprehensive hearing loss history and formulate a treatment plan.

ACGME competency goals Patient Care

Refine the ability to recognize, describe and categorize acquired and congenital hearing loss.

Patient Care Medical Knowledge

Know the most common causes of sensorineural vs conductive hearing loss.

Patient Care Medical Knowledge Patient Care

Perform an efficient physical examination for hearing loss, including tuning fork exam, otomicroscopy, cranial nerve exam, pneumo-otoscopy, and know whn additional testing is needed Understand audiometric testing, and how to fully interpret their findings to direct care. Refine the ability to discuss patient data with audiologists to optimize care.

Understand the basics of hearing aid types, styles, limitations, and the fitting process.

Understand the options of surgical correction of conductive hearing loss (stapedectomy, ossiculoplasty) including their indications, limitations, and the relevant anatomic variations that could be encountered intraoperatively.

Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care

Gain additional familiarity with intraoperative evaluation of ossicular chain mobility, and understand the reconstructive options that are available for a given patient. Be able to place the majority of ossicular prostheses.

Patient Care

Be able to assess patients for possible cochlear implantation. Be able to discuss the indications, surgery, postoperative expectations, and need for rehabilitation services. Be able to perform the majority of cochlear implantation with intraoperative supervision.

Patient Care Medical Knowledge Interpersonal and Communication Skills

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Goal 5. Neurotology. Diagnose and manage patients with skull base disease Resident Objectives: Refine the understanding of skull base anatomy to understand the influence of anatomic and pathologic variability on treatment options and patient care.

Be able to obtain a detailed history related to extra-axial neoplasms and other lesions of the internal auditory canal, cerebellopontine angle, temporal bone and posterior fossa. Incorporate relevant patient data into an efficient and optimized care plan.

Understand the surgical anatomy, signs, symptoms and clinical diagnosis of lesions of the petrous apex. Refine an understanding for which lesions require immediate treatment, and which do not.

Understand the interpretation of radiologic studies used to diagnose lesions of the posterolateral skull base. Be able to combine different modalities in formulating a diagnosis.

Be able to effectively use ancillary tests (e.g. angiography, electrodiagnostic studies, nuclear studies) to evaluate skull base lesions.

Be able to evaluate a patient with vestibular schwannoma in the clinic, and formulate a reasonable treatment plan based on findings, radiology, and patient preferences.

Be able to recognize complications of cranial base surgery, including vascular injury, spinal fluid leak, cranial neuropathy, infection, and CNS injury. Recognize the causative factors, and formulate a basic management plan.

Refine the ability to collaborate at a high level with a multidisciplinary team to provide comprehensive care for patients with skull base lesions.

ACGME Competency Goals Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge

Understand the options for benign lesions of the postero-lateral skull base including watchful waiting, focused radiation, and microsurgical resection. Have a basic understanding of treatment planning for stereotactic radiosurgery.

Goal 6. Audiology. Understand the methods available to test the hearing, and how to interpret the tests.

Resident Objectives: Be familiar with the indications for various audiometric tests including pure-tone testing, word recognitions scores, reflex testing, tympanometry). Understand how to use these tests efficiently in the context of clinical findings.

ACGME competency goals Patient Care Medical Knowledge

101

Be familiar with interpreting audiometric testing, including their accuracy, reliability, and impact on clinical care.

Be able to perform routine tympanograms and audiograms.

Patient Care Medical Knowledge Patient Care Medical Knowledge

Understand specialized electodiagnostic studies and their indications (including ABR, ECOG, VEMP, rotational chair, posturography testing, VNG, etc). Understand how they can guide further treatment.

Goal 7. Facial Nerve

Patient Care Medical Knowledge

Resident Objectives: Understand the surgical anatomy of the facial nerve and its common disorders, including their natural history, clinical presentation, evaluation and treatment.

ACGME competency goals Patient Care Medical Knowledge Patient Care Medical Knowledge

Be able to identify and decompress the intratemporal facial nerve with supervision as clinically indicated. Be able to perform the majority of facial nerve neurorrhaphy, including donor graft harvest.

Goal 8. General Otology Resident Objectives Be able to obtain an appropriate history regarding external ear disease. Understand cutaneous disorders that may be related and the indications for biopsy.

Become more comfortable with clinical otologic procedures including myringotomy, and intratympanic injections. Be familiar with local anesthetic used for outpatient otologic procedures.

Be able to discuss the basics of intratympanic treatment, including the procedure, its risks, benefits, and expectations.

Be able to effectively evaluate and treat the majority of patients complaining of tinnitus.

Refine the approach to patients with otalgia, including an understanding of when to involve consultation for non-otologic etiologies.

ACGME Competency Goals Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge

102

Refine the interaction with other related consult services for patients with otologic complaints.

Further develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of otologic care.

Patient Care Interpersonal and Communication Skills Professionalism Systems-Based Practice

Develop an improved understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Professionalism

Become a more intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

Professionalism Practice-Based Learning and Improvement

Develop an understanding of OHNS coding and compliance issues in otology/ neurotology.

Professionalism Systems-Based Practice

Goal 9. Nasal cavity and sinuses. Diagnose and manage patients with nasal problems.

Resident Objectives Be familiar with the EMR at Stanford (EPIC) to confidentially access appropriate patient information, past culture results, pathology reports and past imaging studies.

Know the anatomy, pathophysiology, and development of the nasal cavity and sinuses.

ACGME Competency Goals Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge

Perform literature searches to investigate common and rare patient presentations, and to obtain evidence for current practice paradigms in patient care.

Medical Knowledge Practice-Based Learning and Improvement

Evaluate consult patients with sinonasal disorders with the senior residents and faculty. Be able to document and communicate recommendations and plan with the primary team in a professional and courteous manner.

Understand principles and utility of CT versus MRI imaging of the sinuses. Understand and describe anatomic variations of the 4 pairs of paranasal sinuses, patterns of uncinate process attachment and sinus drainage patterns.

Professionalism Medical Knowledge Interpersonal and Communication Skills

103

Be able to obtain a detailed history related to the nose and nasal problems related to sinus disease and allergic rhinitis.

Perform safe, informative routine office nasal endoscopy with 0 degree and 30 degree rigid endoscopes.

Access and understand AAO descriptive guidelines for acute, subacute and chronic sinusitis, and know the major and minor symptoms associated with diagnosis of sinusitis.

Evaluate patients with chronic sinusitis with and without polyposis – and distinguish which patients may require surgery or medical therapy.

Be able to describe and recognize complications of acute sinusitis.

Identify the signs and symptoms and differences between allergic rhinitis and acute/chronic sinusitis.

Understand indications for safe intranasal office biopsy.

Be proficient with the evaluation and management algorithms for treating epistaxis.

Understand options for treatment of nasal septal deviation and turbinate hypertrophy.

Learn the assembly of equipment needed to perform nasal endoscopy, and intraoperative image guidance.

Complete basic aspects of endoscopic approaches to the nasal cavity – including use of zerodegree and 30 degree endoscopes, safely navigating the nasal cavity with mucosal preserving technique, performing septoplasty, turbinate reduction, maxillary antrostomy, and anterior ethmoidectomy.

Goal 10. Understand the basics of the aesthetic patient consultation Resident Objectives:

Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge Professionalism Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge

ACGME Competency Goals

104

Understand and be able to perform psychological assessment for potential aesthetic surgery patients.

Describe how to perform outpatient filler or botulinum toxin injections.

Know literature regarding efficacy of facial rejuvenation procedures.

Understand basic medical photography.

Goal 11. Understand the approach to the rhinoplasty patient Resident Objectives: Understand and provide psychological assessment for potential rhinoplasty patients.

Understand anatomy of the internal and external nasal valve and repair.

Know literature regarding efficacy of nasal surgical procedures.

Understand basic aesthetic nasal analysis.

Goal 12. Understand the approach to the facial trauma patient Resident Objectives: Be able to assess and perform soft tissue repair.

Understand pathophysiology of facial fractures and provide effective plan of care.

Understand the biomechanics of fixation for fractures Know literature regarding facial trauma.

Medical Knowledge Patient Care Medical Knowledge Medical Knowledge Medical Knowledge ACGME Competency Goals Medical Knowledge Patient Care Medical Knowledge Medical Knowledge Medical Knowledge ACGME competency goals Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care

Goal 13. Understand the approach to the facial nerve trauma patient Resident Objectives: Be able to explore the extratemporal facial nerve.

Be able to discuss options for treatment of facial nerve paralysis.

ACGME Competency Goals Medical Knowledge Medical Knowledge Patient Care Interpersonal and Communication Skills 105

Goals and Objectives PGY 5: SHC Specialty Service Competency-based Goals and Objectives Goal 1. Consults in an adult hospital. Continue to learn about consults requested regarding otologic problems.

Resident Objectives: ACGME Competency Goals Provide backup resident evaluation for all consults from other SHC services and the Patient Care emergency department. Effectively oversee the discussion of all consults on daily rounds.

Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-Based Practice See consult patients as indicated, and formulate a plan for care. Discuss with attending staff as Patient Care needed. Oversee the implementation of all clinical plans.

Medical Knowledge Develop a comprehensive understanding of the SHC electronic medical record (Epic) and be Patient Care able to access information appropriately. Understand the importance of confidentiality in Professionalism patient medical records. Provide backup and instruction for the other resident team members Systems-Based Practice for its use.

Learn to effectively run an inpatient service. Understand how to assign duties appropriate for Patient Care each resident’s level of training. Provide administrative leadership to cover consults, operative Medical Knowledge cases, and outpatient clinic.

Systems-Based Practice Interpersonal and Communication Skills Establish competency as a leader for teaching on rounds and assigning academic duties to the Medical Knowledge resident team.

Practice-Based Learning and Improvement Understand how to oversee all communications between the resident service and other services who share common patients. Learn how to be accurate, professional, and efficient in these interactions.

Establish leadership skills in planning academic meetings, conferences, and schedules.

Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice 106

Refine effective time-management skills given expected additional time constraints imposed by academic duties.

Practice-Based Learning and Improvement

Learn to integrate varied patient care styles from different attendings, and use these to develop personal preferences.

Patient Care Systems-Based Practice Professionalism

Lead Skull Base Tumor rounds discussions, understand issues examined, and implement decisions as required.

Systems-Based Practice

Goal 2. Chronic Otitis Media. Screen, diagnose and manage patients with symptoms secondary to their chronic ear infections.

Resident Objectives: Develop a comprehensive understanding of the surgical anatomy, physiology, and pathophysiology of the middle ear and mastoid. The depth of understanding should allow the resident to operate independently in the great majority of chronic ear procedures.

Take a refined history focused on issues related to recurrent and chronic ear infections, and formulate an optimized plan of care.

Order and interpret diagnostic tests for assessing otologic disease (e.g. CT and MRI imaging, audiology, tympanometry). Refine efficiency in ordering tests and establish individualized protocols for managing chronic ear disease.

Be able to assess the ear on exam. Develop mastery of the binocular microscope and otoendoscopy. Understand what findings necessitate operative intervention, and which can be treated in the outpatient clinic.

Be able to teach junior residents and medical students the basics of middle ear disease.

Refine the ability to counsel parents regarding the pathophysiology of conditions associated with chronic otitis, its risks, and treatment options.

ACGME Competency Goals Medical Knowledge

Patient Care Patient Care Medical Knowledge Systems-Based Practice Patient Care Patient Care Patient Care Interpersonal and Communication Skills

Understand the indications for surgical intervention, its risks and potential complications.

Understand how history and anatomy influence surgical treatment planning. Be able to formulate an independent plan for management of broad categories of middle ear disease.

Patient Care Medical Knowledge

Be able to appropriately manipulate even difficult ears in the clinic with a minimum of patient discomfort. Develop the confidence and reassuring tone to enable this.

Interpersonal and Communication Skills Patient Care

107

Know the management and expected postoperative course of patients who undergo tympanomastoid surgery. Be able to answer the postoperative questions/ concerns, and arrange for appropriate follow-up care.

Be able to safely and efficiently perform the majority of tympanomastoid surgery including mastoidectomy, transcanal procedures, ossiculoplasty, etc.

Patient Care

Be able to safely work in anatomically challenging middle ears with unconventional anatomy.

Be able to take junior residents through the basic steps of tympanomastoid surgery.

Develop a comprehensive understanding of the natural history of chronic ear disease and its response to treatment.

Goal 3. Vertigo. Be able to evaluate and treat peripheral vestibular disease.

Resident Objectives: Refine the understanding of the anatomy, physiology, and pathophysiology of the vestibular system (both peripheral and central), and how it impacts clinical presentation.

Patient Care Patient Care Patient Care

Be able to take a history related to balance and vertigo. Formulate a directed and practical differential diagnosis.

Patient Care Interpersonal and Communication Skills Patient Care

Know how to perform clinical examination of patients with vestibular complaints.

Differentiate peripheral from central pathology. Incorporate the interpretation of specialized vestibular tests.

Be able to formulate, present and carry out an incremental approach to treating peripheral vestibulopathy.

Refine the ability to discuss factors involved in vertigo and balance dysfunction with patients and families.

Be able to counsel parents about the various treatment options available for management of Meniere’s disease, paroxysmal positioning vertigo, and vestibular neuronitis, superior semicircular canal dehiscence, etc. Discuss medical vs surgical approaches, and formulate an understanding of the role of surgery in these disorders.

Be able to interpret the subtleties of vestibular function tests (VNG, VEMP, ECOG, etc), and use them in forming a treatment plan.

Patient Care

ACGME competency goals Medical Knowledge

Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge 108

Be able to discuss care of vertigo patients with providers from other specialties to formulate a care plan involving a number of disciplines. Understand the role of otolaryngologist and other specialists in the management of vestibular disorders.

Be familiar with the surgical management of peripheral vestibular disease, and be able to perform the majority of the steps necessary for their successful completion – including selective canal plugging, vestibular neurectomy, and labyrinthectomy.

Goal 4. Hearing Loss Resident Objectives: Be able to obtain a comprehensive hearing loss history and formulate a treatment plan.

Refine the ability to recognize, describe and categorize acquired and congenital hearing loss.

Be able to formulate an appropriate and cost-effective work-up for retrocochlear diagnosis, and evaluation of congenital hearing loss.

Perform an efficient physical examination for hearing loss, including tuning fork exam, otomicroscopy, cranial nerve exam, pneumo-otoscopy, and know when additional testing is needed.

Understand audiometric testing, and how to fully interpret their findings to direct care. Refine the ability to discuss patient data with audiologists to optimize care.

Understand the basics of hearing aid types, styles, limitations, and the fitting process. Have a basic understanding of how to incorporate hearing aid dispensing into an otolaryngologic practice.

Understand the options of surgical correction of conductive hearing loss (stapedectomy, ossiculoplasty) including their indications, limitations, and the relevant anatomic variations that could be encountered intraoperatively.

Gain clinical competence in the intraoperative evaluation of ossicular chain mobility, and understand the reconstructive options are available for a given patient. Be able to place the ossicular prostheses. Be able to perform the majority of uncomplicated stapes surgery.

Be comfortable in evaluating cochlear implant candidates. Be able to discuss the indications, surgery, postoperative expectations, and need for rehabilitation services. Present the different type of devices available, and understand current areas of clinical research that may implant care. Be able to perform the majority of cochlear implantation.

Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Interpersonal and Communication Skills ACGME competency goals Patient Care Patient Care Medical Knowledge Patient Care Systems-Based Practice Patient Care Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Patient Care Patient Care Medical Knowledge Interpersonal and Communication Skills

109

Goal 5. Neurotology. Diagnose and manage patients with skull base disease Resident Objectives: Refine the understanding of skull base anatomy to understand the influence of anatomic and pathologic variability on treatment options and patient care. Be able to list the clinical and radiographic presentation of skull base lesions.

Refine the ability to obtain a detailed history related to extra-axial neoplasms and other lesions of the internal auditory canal, cerebellopontine angle, temporal bone and posterior fossa.

Incorporate relevant patient data into an efficient and optimized care plan.

Understand the surgical anatomy, signs, symptoms and clinical diagnosis of lesions of the petrous apex, clivus, and jugular foramen. Refine an understanding for which lesions require immediate treatment, and which do not.

Understand the interpretation of radiologic studies used to diagnose lesions of the posterolateral skull base. Be able to combine different modalities in formulating a diagnosis and appropriate treatment plan.

Be able to effectively order and interpret ancillary tests (e.g. angiography, electrodiagnostic studies, nuclear studies) to evaluate skull base lesions. Discuss the findings effectively with radiologists.

Be able to evaluate a patient with vestibular schwannoma and similar lesions, and formulate a reasonable treatment plan based on findings, radiology, and patient preferences. Formulate a work-up and treatment plan for patients with NF-2.

Be able to recognize complications of cranial base surgery, including vascular injury, spinal fluid leak, cranial neuropathy, infection, and CNS injury. Recognize the causative factors, and formulate a basic management plan. Understand methods and tehniques to avoid such complications.

Refine the ability to collaborate at a high level with a multidisciplinary team to provide comprehensive care for patients with skull base lesions.

Understand the options for benign lesions of the postero-lateral skull base including watchful waiting, focused radiation, and microsurgical resection. Be familiar with treatment planning for stereotactic radiosurgery for uncomplicated lesions of the cranial base.

ACGME Competency Goals Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge

110

Be able to perform the majority of surgical approaches to the cranial base including Patient Care transmastoid approaches to the jugular foramen, petrous apicectomy, translabyrinthine approaches, and middle fossa craniotomy.

Goal 6. Audiology. Understand the methods available to test the hearing, and how to interpret the tests.

Resident Objectives: Be familiar with the indications for all used audiometric tests including pure-tone testing, word recognitions scores, sentence testing, reflex testing, tympanometry). Understand how to use these tests efficiently in the context of clinical findings.

Be familiar with interpreting audiometric testing, including their accuracy, reliability, and impact on clinical care.

Be able to perform routine tympanograms and audiograms.

Understand specialized electodiagnostic studies and evokes responses and their indications (including ABR, ECOG, VEMP, rotational chair, posturography testing, VNG, etc).

Understand how they can guide further treatment.

Goal 7. Facial Nerve Resident Objectives: Understand the surgical anatomy of the facial nerve and its common disorders, including their natural history, clinical presentation, evaluation and treatment.

Be able to find and decompress the intratemporal facial nerve with supervision as clinically indicated. Be able to perform the majority of facial nerve neurorrhaphy, including donor graft harvest. Be comfortable with techniques of facial nerve re-routing.

Goal 8. General Otology Resident Objectives: Be able to independently manage uncomplicated cutaneous lesions of the external ear canal and pinna. Be able to communicate the treatment options and expectations with the patient.

Be able to perform clinic-based otologic procedures including myringotomy, and intratympanic injections. Be familiar with local anesthetic used for outpatient otologic procedures.

Be able to discuss the basics of intratympanic treatment, including the procedure, its risks, benefits, and expectations.

ACGME Competency Goals Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge ACGME Competency Goals Patient Care Medical Knowledge Patient Care Medical Knowledge

ACGME Competency Goals Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge

111

Be able to effectively evaluate and treat the majority of patients complaining of tinnitus and the spectrum of other non-surgical otologic complaints.

Further refine the care of otalgia, including an understanding of when to involve consultation for non-otologic etiologies and when to consult other specialists (pain service, oral surgery, laryngology, etc).

Be able to teach junior residents and medical students in the approach to outpatient otology.

Further develop an understanding of and sensitivity to the impact of cultural, economic and ethnic factors in the doctor-patient relationship and the delivery of otologic care.

Develop an improved understanding of one’s own abilities and limitations including awareness of signs of fatigue.

Become a more intelligent user of the academic literature in otolaryngology. Demonstrate the ability to apply knowledge of study designs and statistical methods to appraise clinical studies.

Perform literature searches as needed to continuously improve the level of medical knowledge.

Develop an understanding of OHNS coding and compliance issues in otology/ neurotology.

Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Professionalism Systems-Based Practice Professionalism Professionalism Practice-Based Learning and Improvement Professionalism Systems-Based Practice

Goal 9. Understand the basics of the aesthetic patient consultation Resident Objectives: Be able to perform a blepharoplasty (upper or lower).

ACGME Competency Goals Medical Knowledge Patient Care

Goal 10. Understand the approach to the rhinoplasty patient Resident Objectives: Be able to perform an effective functional or aesthetic septorhinoplasty.

Goal 11. Understand the approach to the facial trauma patient Resident Objectives: Be able to perform repair of frontal sinus, naso-orbito-ethmoidal, maxillary, orbital, and mandibular fractures.

Goal 12. Understand the approach to the facial trauma patient

ACGME Competency Goals Patient Care Medical Knowledge ACGME competency goals Patient Care Medical Knowledge

112

Resident Objectives: Be able to perform a canthoplasty and gold weight procedure.

ACGME competency goals Medical Knowledge Patient Care

Goal 13. Nasal cavity and sinuses. Diagnose and manage patients with nasal problems.

Resident Objectives:

ACGME Competency Goals

Be familiar with the EMR at Stanford (EPIC) to confidentially access appropriate patient information, past culture results, pathology reports and past imaging studies.

Patient Care Professionalism Systems-Based Practice Patient Care Medical Knowledge Systems-Based Practice Interpersonal and Communication Skills Medical Knowledge

Effectively comprehensively manage primary inhouse, post-operative and consult patients with sinonasal disorders with the junior and senior residents.

Know the endoscopic anatomy and pathophysiology of the sinuses, paranasal skullbase, and extended skullbase including pterygopalatine fossa, infratemporal fossa, orbit, sella, lateral sphenoid recess, clivus and anterior skullbase.

Perform literature searches to prepare for public presentations on rhinology topics, and effectively present in quality assurance conferences in a professional and composed manner.

Understand radiographic nuances of sinonasal disease processes using both CT versus MRI imaging – sinonasal neoplasms, intraorbital pathology, pneumocephalus, suprasellar intracranial disease.

Understand the posterior, lateral, inferior, and superior limits of endoscopic approaches to the skullbase Understand fungal sinusitis, including fungal ball versus allergic fungal sinus disease versus invasive fungal sinusitis.

Evaluate patients with chronic sinusitis with and without polyposis – and distinguish which patients may require surgery or medical therapy.

Evaluate patients with chronic sinusitis who have received prior surgery. Understand indications for revision surgical procedures versus use of medical therapies.

Medical Knowledge Practice-Based Learning and Improvement Professionalism Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge Medical Knowledge Systems-Based Practice Patient Care Medical Knowledge Professionalism Patient Care Medical Knowledge 113

Professionalism Perform proper office debridement of the maxillary, ethmoid, sphenoid and frontal sinuses in the immediate post-operative setting with minimal patient discomfort.

Understand the etiology of sinusitis in the setting of immunosuppression, and surgically manage patients with invasive fungal sinus disease.

Identify the signs and symptoms of more rare intranasal pathology, such as autoimmune disease (Wegener’s) and granulomatous (Churg-Strauss) disease.

Understand and describe complications of endoscopic sinus surgery, including orbital injury, CSF leak, synechiae formation, middle turbinate lateralization and need for revision surgery.

Be able to effectively and compassionately counsel patients of these details.

Utilize more advanced equipment and instrumentation to access the nasal cavity – including use of 30, 45, and 70 degree endoscopes to access areas of the nasal cavity, use of hand instrumentation and powered instruments such as microdebriders and drills, and endoscopic cautery tools.

Perform safe and methodical endoscopic sinus surgery, including skullbase dissection, frontal sinusotomy, modified Lothrop procedure, and revision endoscopic sinus surgery.

Understand principles and techniques for performing open skullbase surgery, including frontal sinus obliteration, cranialization, and Reidel procedures.

Demonstrate appropriate surgical technique for advanced endoscopic orbital surgery, including endoscopic dacrocystorhinostomy (DCR) and orbital decompression. Work effectively with the Opthalmology service to coordinate patient intraoperatively and on the floors.

Patient Care Medical Knowledge Professionalism Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Patient Care Medical Knowledge Interpersonal and Communication Skills

Understand and appropriately use reconstructive ladders for intranasal and skullbase lesions, including free tissue grafts, pedicled mucosal tissue flaps, pericranial flaps, and free flaps.

Patient Care Medical Knowledge

Perform safe and efficient endoscopic resection of anterior midline skullbase pathology with reconstruction. Work closely and effectively with a neurosurgical service in coordinated surgical efforts when required.

Patient Care Medical Knowledge Interpersonal and Communication Skills

114

Santa Clara Valley Medical Center Rotation Contacts and Scheduling Details Rotation Director:

Misha Amoils, MD Misha.Amoils@hhs.sccgov.org

Attendings: Amoils, Lalakea, Munoz, Saste, Shepard Introduction Santa Clara Valley Medical Center is located 25 minutes south of Stanford University, and is a county hospital facility. Rotations at this facility complement the residency experience by providing exposure to a culturally diverse, medically indigent population with a broad range of OTO/HNS pathology.

The R2 resident should review the R3 Research Rotation Goals and Objectives. The research plan must be completed during the R2 year.

Additional Required Conferences: o All VMC OTO/HNS Teaching Conferences: o OTO/HNS Radiology Conference, OTO/HNS Pathology Conference (each conference once monthly). o Monthly Stanford Faculty meetings (Chief Residents)

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Weekly Schedule

Clinic

Time

Monday

Tuesday

Wednesday

Thursday

Friday

6:00-7:00 8:00-9:00

Rounds Res Ed at Stanford

Rounds

Rounds

Rounds

Rounds

All Day 6:00-18:00

Inpatient consults for R2 and R5 residents Gen Clinic Lalakea, Munoz Gen Clinic Lalakea

Gen Clinic Shepard, Munoz Gen Clinic Munoz

Gen Clinic Saste Gen Clinic Amoils

8:00-12:00 12:00-16:00

Gen Clinic Saste Gen Clinic Amoils, Lalakea

Gen Clinic Saste, Amoils Gen Clinic Amoils, Shepard

Radiology conference (Every 4th Thursday)

12:00-13:00

Pathology conference

OR

(Every 2nd Thursday)

8:30-17:30 7:30-17:30 7:30 -17:30 7:30 -17:30 7:30 -17:30 18:00-19:00

OR Shepard (4th Saste) OR Lalakea OR Amoils OR 1st, 3rd, 5th : Saste OR Munoz Grand Rounds at Stanford

2nd resident to assist in OR M, T, W, Th, F afternoons at conclusion of clinic.

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Rotation Specifics 1. Rounding: Residents are expected to round daily before O.R. and daily after clinic/OR. Residents are expected to round daily on weekends-generally beginning before noon. The chief resident is expected to teach junior residents while on rounds.

2. The attending on call should be phoned after rounds and given the patient update. Call other attendings as needed for specific patient issues.

3. The attending on call should be called about all admissions to the hospitals, all patients going to the operating room and all complicated evening or nighttime consults.

4. Consult patients should be seen and evaluated within ½ day of receiving the consult and discussed with the attending. Attending will sign off within 24 hours.

5. OR cases should be covered by the appropriate level residents with attending faculty present. Residents are expected to hand down cases as appropriate. Operative reports should be dictated/typed the day of the procedure.

6. Cases going on after 5 pm should be covered by the on-call resident if local to Valley, otherwise the appropriate level resident. If a senior level case is going on and no clinics are in process then a junior resident is encouraged to scrub in and assist with case.

7. Pre-ops should be reviewed the week prior. Residents are expected to know the patient information.

8. Residents are expected to wear a clean white coat. Business casual attire is preferred but scrubs are acceptable.

9. Residents are released from duty when the work is done with attention to resident work hours and patient care.

10. Residents are expected to attend all Thursday evening conferences. Residents should discuss with faculty members how faculty can help residents get to conference on time.

11. Chief residents are expected to attend the monthly Stanford faculty meetings.

Evaluation and Feedback The Santa Clara Valley Medical Center faculty, and selected ancillary medical personnel will complete written evaluations at the end of the rotation. Selected clinic patients will evaluate the residents. Residents will be asked to evaluate each Faculty Member and the rotation. Daily feedback on physical findings, assessment, plan, and surgical technique will occur through clinical interactions.

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Goals and Objectives PGY 2: SCVMC Competency-based Goals and Objectives Goal 1: Learn how to evaluate and counsel otolaryngology patients with common conditions related to the head and neck.

Resident Objectives: ACGME Competency Goals Regularly attend outpatient clinics and learn a complete head and neck history and examination on adult and pediatric patients with attending supervision/verification of positive/negative findings.

Begin to attain an understanding of appropriate work-up and available medical and surgical treatment options for adults with common conditions such as chronic otitis media, nasal obstruction, sleep apnea, chronic sinusitis, gastroesophageal reflux, asymmetric sensorineural hearing loss, vocal cord paralysis, epistaxis, head and neck malignancy, and otitis externa.

Patient Care Medical Knowledge

Be able to effectively counsel patients regarding the treatment alternatives, indications, risks, benefits, and expected post-operative course of basic surgical procedures such as:

Patient Care Medical Knowledge Interpersonal and Communication Skills

o Uvulopalatopharyngoplasty o Septoplasty o Turbinate reduction o Tracheotomy o Tympanoplasty o Excisional biopsy of neck mass o Laryngoscopy, esophagoscopy, and bronchoscopy Be able to effectively counsel patients regarding medical ENT topics such as presbycusis, tinnitus, control of seasonal allergies, head and neck cancer risk factors, and smoking cessation.

Learn basic audiologic principles and understand the interpretation of audiologic tests.

Begin to develop a practical and cost-effective approach to providing excellent care within the constraints of resources available to uninsured/under-insured patients.

Begin to develop competency in recognizing emergencies in the adult and pediatric patient, including airway emergencies.

Patient Care Medical Knowledge

Patient Care Medical Knowledge Interpersonal and Communication Skills Medical Knowledge Systems-Based Practice Patient Care Patient Care 118

Learn the nuances of performing fiberoptic nasopharyngoscopy and laryngoscopy.

Learn to perform pneumatic otoscopy to improve accuracy in the diagnosis of middle ear effusion.

Learn the ways in which normal pediatric anatomy may differ from adult anatomy, and the appearance of common pediatric disorders.

Learn to obtain a directed history and exam for common pediatric problems such as sleep apnea, hearing loss, speech delay, epistaxis, and stridor.

Be able to discuss appropriate work-up and management for pediatric conditions such as otitis media, sleep disorders, sinusitis, laryngomalacia, recurrent respiratory papillomatosis, and neck masses.

Be able to effectively counsel patients/families regarding the treatment alternatives, indications, risks, benefits, and expected postop recovery of the following procedures: o Pressure equalizing tube placement o Tonsillectomy o Adenoidectomy o Laryngoscopy and bronchoscopy o Excision of neck mass (e.g. thyroglossal duct cyst) o Tracheostomy o Tympanoplasty Be able to effectively counsel patients/families regarding medical ENT topics such as congenital hearing loss, risk factors for otitis media, second-hand smoke risks, epistaxis prevention.

Develop a sense of empathy regarding the barriers that conspire to prevent patients from receiving optimal healthcare (lack of transportation, language barriers, socioeconomic status, cultural differences, education level, family support, etc.).

Understand the importance of confidentiality in patient medical records, patient care, and patient related communications.

Begin to develop an understanding of one's own abilities and limitations, including fatiguemanagement, and a commitment to life-long learning and improvement.

Patient Care Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills Patient Care Medical Knowledge Patient Care Interpersonal and Communication Skills

Patient Care Interpersonal and Communication Skills Patient Care Interpersonal and Communication Skills Professionalism Professionalism Interpersonal and Communication Skills Practice-Based Learning and Improvement Professionalism 119

Become a competent user of the literature in otolaryngology, through targeted literature searches and critical review of literature, to direct patient care and improve medical knowledge.

Develop an understanding of OHNS documentation, coding and compliance issues.

Practice-Based Learning and Improvement Systems-Based Practice Professionalism

Goal #2: Learn to perform basic otolaryngology procedures Resident Objectives: ACGME Competency Goals Be able to competently perform the following procedures with direct attending supervision: Patient Care o Tympanostomy tube placement o Tonsillectomy and adenoidectomy o Endoscopy, including direct laryngoscopy, suspension laryngoscopy, esophagoscopy, and bronchoscopy in children and adults o Routine tracheotomy o Removal of simple neck masses/cysts o Repair of complex facial lacerations o Removal of uncomplicated esophageal foreign bodies o Incision and drainage of neck abscess Be able to assemble the equipment needed to perform a laryngoscopy, bronchoscopy and Patient Care esophagoscopy.

Learn to set up, test, and operate the CO2 laser with appropriate attention to laser safety, with Patient Care supervision.

Goal #3: Begin to appreciate systems-based understanding of otolaryngology practice and general OHNS issues Resident Objectives: ACGME Competency Goals Attend monthly staff meeting.

Systems-based practice Begin to appreciate importance of E&M and procedure coding, surgical procedures, Systems-Based Practice consultations, and outpatient visits (CPT and ICD-9).

Professionalism Begin to understand the importance of documentation to support coding levels and to comply Systems-Based Practice with insurance payor regulations (e.g. Medicare).

Professionalism Begin to develop sense of empathy regarding the barriers that conspire to prevent patients Patient Care from receiving optimal healthcare (lack of transportation, language barriers, socioeconomic Interpersonal and Communication Skills status, cultural differences, education level, family support, etc.)

Professionalism Understand the importance of maintaining confidentiality in patient medical records, patient Professionalism care, and patient related communications.

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Goals and Objectives PGY 5: SCVMC Competency-based Goals and Objectives Goal #1: Know how to evaluate, counsel and treat otolaryngology patients.

Resident Objectives: Exhibit confidence and independence while pursuing a well-reasoned approach to the evaluation and management of the full spectrum of OTO/HNS patients.

ACGME Competency Goals Professionalism Medical Knowledge Patient Care

The R5 will be able to efficiently execute the evaluation of most patients without major changes being suggested by supervising faculty.

Medical Knowledge Patient Care Medical Knowledge Patient Care Practice-Based Learning and Improvement

Demonstrate a command of relevant current literature and be able to apply it in the development of an evaluation and (surgical and/or non-surgical) treatment plan for the full spectrum of OTO/HNS problems such as: Head and neck malignancy o Complicated sinonasal disease o Complex facial trauma o Complex oto-neurotologic complaints o Structural and functional voice/swallowing disorders o Thyroid and parathyroid disorders Demonstrate confidence and competence in the management of OTO/HNS emergencies, along with the skills needed to effectively lead the patient care team. o

Demonstrate the ability to think ahead and contingency plan to avoid errors caused by lack of equipment, lack of staff, or lack of appropriate attending or specialty back-up, and to communicate effectively while leading the patient-care team .

Patient Care Medical Knowledge Professionalism Interpersonal and Communication Skills Systems-Based Practice Medical Knowledge Interpersonal and Communication Skills Professionalism 121

Recognize and anticipate complications such as airway compromise, hemorrhage, hematoma, infection, CSF leak, and fistula.

Develop and execute a treatment plan to manage such complications, while taking responsibility as appropriate, and using such experiences to improve patient care.

Patient Care Medical knowledge Patient Care Medical Knowledge Professionalism Practice-Based Learning and Improvement

Be able to apply information gained from radiographic studies in the assessment of head and neck lesions, congenital anomalies, paranasal sinus pathology and temporal bone pathology, and understand the appropriate use, overuse, and limitation of these studies.

Systems-Based Practice Medical Knowledge Patient Care

Demonstrate competence in the interpretation of the full range of audiologic studies including ABR, Enog, and OAEs.

Medical Knowledge

Be able to successfully transition from supervision by faculty to primary decision-making with faculty oversight.

Professionalism Medical Knowledge Patient Care

Take primary responsibility for co-directing monthly pathology and radiology teaching conferences with the Pathology and Radiology Departments.

Supervise presentation of complications on the service at monthly Quality Improvement conference, including review of relevant literature.

Interpersonal and Communication Skills

Develop the resident call schedule.

Interpersonal and Communication Skills

Demonstrate competence and organizational skills in directing the resident team in the daily management of in-house patients and OR activities.

Patient Care Professionalism Interpersonal and Communication Skills

Demonstrate ability and commitment in the day-to-day informal teaching and mentoring of students and junior residents.

Be able to competently supervise/assist junior residents performing common OTO/HNS surgical procedures.

Interpersonal and Communication Skills Medical Knowledge Interpersonal and Communication Skills Medical Knowledge

Successfully demonstrate excellent interpersonal skills, effectively setting the tone for other members of the resident team, clinical and non-clinical staff.

Interpersonal and Communication Skills Professionalism

Interpersonal and Communication Skills Practice-Based Learning and Improvement Medical Knowledge

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Demonstrate competence in OHNS coding, compliance, documentation and confidentiality issues.

Demonstrate a high-level of empathy and 'cultural competence' regarding those factors that conspire to prevent patients from receiving optimal healthcare (lack of transportation, language barriers, socioeconomic status, cultural differences, education level, family support, etc.), and an understanding of resources that can be utilized to improve care in these situations Demonstrate a high degree of self-knowledge, including personal strengths and weaknesses, including the ability to expand medical knowledge through literature review, to be appropriately self-critical, and to request assistance and/or consultation as needed.

Goal #2: Be able to safely and efficiently perform advanced otolaryngology procedures Resident Objectives: Be able to competently and efficiently perform advanced otolaryngology procedures with attending supervision such as: o Laryngology • Laryngoplasty • Reconstructive airway surgery o Otology/Neurotology • Tympanomastoidectomy • Ossicular chain reconstruction • Stapedotomy o Head and Neck • Maxillectomy • Partial laryngeal surgery • Composite resection • Total parotidectomy with nerve grafting • Surgical management of aggressive thyroid malignancy • Parathyroidectomy o Rhinology • Revision endoscopic sinus surgery • Orbital decompression

Professionalism Systems-Based Practice Patient Care Interpersonal and Communication Skills Professionalism Systems-Based Practice Professionalism Practice-based Learning and Improvement

ACGME Competency Goals Patient Care

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• Repair of CSF leaks o Facial Plastic and Reconstructive Surgery • Complex facial trauma, such as Le Fort fractures, naso-orbital-ethmoid fractures, and comminuted mandible and midface fractures • Functional rhinoplasty • Repair of post-traumatic and post-ablative defects Goal #3: Develop systems-based understanding of otolaryngology practice Resident Objectives: Attend monthly staff meeting Demonstrate competence in correctly coding surgical procedures, consultations, and outpatient visits (CPT and ICD-9).

Demonstrate competence in appropriately documenting patient care to support coding levels and to comply with insurance payor regulations (e.g. Medicare).

Demonstrate sense of empathy regarding the barriers that conspire to prevent patients from receiving optimal healthcare (lack of transportation, language barriers, socioeconomic status, cultural differences, education level, family support, etc.)

Continue to develop an understanding of one's own abilities and limitations, and a commitment to life-long learning and improvement, through activities such as case presentation at Morbidity and Mortality conference, including directed literature review and discussion of systems improvements as appropriate.

ACGME Competency Goals Systems-based practice Systems-Based Practice Professionalism Systems-Based Practice Professionalism Patient Care Interpersonal and Communication Skills Professionalism Practice-Based Learning and Improvement Professionalism Systems-Based Practice

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Stanford Health Care and Lucile Packard Children’s Hospital Night Float Rotation Rotation Specifics: 1. Night float is on Sunday-Thursday nights from 6 pm to 6 am.

2. All call is in-house.

3. The night float resident will see all consults and take all outside calls which come in after 5pm; be the operative resident on any cases which start after 8:00 pm and will begin taking the floor calls once the hand-off from that team has occurred.

4. Beginning at 7:30 pm the night float resident will take over in any running ORs. Goal 1. Consults. Know how to evaluate and treat inpatient and emergency department consult patients.

Resident Objectives: Be the initial contact resident for all consults at SHC and LPCH services including the emergency department.

Perform initial evaluation of all consult patients.

Be familiar with the EPIC medical record systems and be able to access information appropriately. Understand the importance of confidentiality in patient medical records.

Consistently demonstrate courtesy when interacting with clinical and non-clinical staff members.

Perform a literature search to learn more about unusual patient problems.

Create a complete and coherent consultation note in a timely fashion.

Utilize translation services to communicate with non-English speaking patients as needed.

ACGME Competency Goals Patient Care Medical Knowledge Interpersonal and Communication Skills Systems-Based Practice Patient Care Medical Knowledge Patient Care Professionalism Systems-Based Practice Interpersonal and Communication Skills Professionalism Medical Knowledge Practice-Based Learning and Improvement Interpersonal and Communication Skills Professionalism Interpersonal and Communication Skills Systems-Based Practice Professionalism

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Demonstrate effective time-management skills.

Practice-Based Learning and Improvement

Follow-up on consult patients as needed.

Patient Care Systems-Based Practice Professionalism

Goal 2. Hand-offs. Know how to receive and give hand-offs.

Resident Objectives: Receive and give hand-offs in a thorough and efficient manner.

ACGME Competency Goals Patient Care Interpersonal and Communication Skills Professionalism Patient Care

Demonstrate effectiveness in following up all to-do items communicated through the hand-off process.

Goal 3. Patient phone calls. Know how to appropriately communicate with patients via the phone.

Resident Objectives: ACGME Competency Goals Be able to obtain an appropriate history from patients who call in through the hospital Patient Care operators.

Interpersonal and Communication Skills Be able to direct outside patients appropriately.

Patient Care Interpersonal and Communication Skills Be able to appropriately document patient phone calls in the medical record.

Patient Care Systems-Based Practice Goal 4. Operative experience. Know how to perform surgical procedures in the after business-hours setting.

Resident Objectives: ACGME Competency Goals Be able to perform procedures which must be done on an urgent basis after normal business Patient Care hours.

Be able to rapidly learn a patient’s history and step in to assist in surgery which is on-going.

Patient Care Medical Knowledge

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OHNS Resident Research Program Introduction: The R3 resident will have one three-month block of dedicated research time to engage in one or more projects. In addition there will be some protected research time when on rotation at the VAPA. Each resident must have a full-time Stanford faculty advisor and may have an additional direct research advisor if the research is performed outside the Otolaryngology department. This rotation is intended to give the resident maximum flexibility regarding the subject matter of the research project.

PGY1 / PGY2 During the PGY1 rotations on Otolaryngology and the first PGY2 rotation, the resident should investigate departmental projects and arrange to meet with at least three Otolaryngology faculty members to discuss possible research projects for the research rotation.

PGY2 Summer/Fall Deadline: January/February of PGY2 year (be prepared to discuss at the time of semiannual meeting with program director.)

After review and discussion the resident selects a project and with the help of their advisor writes a two-page proposal detailing how the research block will be spent (see below for details).

The research proposal should consist of: ▪

Your faculty advisor’s name (must be Stanford full-time faculty). You may have an adjunct clinical faculty member or non-faculty member as your direct research advisor, with the approval of your faculty advisor. Submit both names, if appropriate.

▪

Written proposal: o Specific Aims and Significance. What question are you trying to answer and what is the significance of that question? o Background and Literature Search. Summarize previous relevant work in the area; demonstrate that you have done your homework with an annotated bibliography and explain how other studies have been lacking. o Methodology. How do you plan to answer your question or questions? How many animals and what type and how did your choose that animal? What type of lab equipment will you be using? For those studies requiring a clinical chart review, how many charts do you intend to review, where, and how will you get the charts? What problems do you anticipate and how do you think these can be overcome? o Data. For all proposals, how will the data be analyzed? What statistical methods will be used? o Budget. This must be detailed and appropriately justified. Rough estimates are not acceptable. o Bibliography.

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The goals and objectives of the research program are outlined in the table on the proceeding page.

Competency-based Goals and Objectives: PGY3/4 – Research Goal 1. Be able to construct a plan for research Resident Objectives:

ACGME Competency Goals

Construct a research plan and create a research proposal (including Specific Aims and significance, Background and literature search, methodology, Data analysis plan, Budget, Bibliography). This should be done during the R1 and R2 years.

Systems-Based Practice

Complete the mandatory education programs for investigators involved in human and/or animal research.

Professionalism Systems-Based Practice

Complete the Human Subjects and/or Animal subjects applications and submit in a timely fashion.

Professionalism Systems-Based Practice

Present your research plan two months before the official research rotation begins.

Interpersonal and Communication Skills

Goal 2. Know how to carry out a research project Resident Objectives:

ACGME Competency Goals

Complete the data acquisition portion of the research plan.

Systems-Based Practice

Demonstrate an ability to adapt the research plan (“troubleshoot”) based on unexpected results or difficulties.

Professionalism Interpersonal and Communication Skills

Demonstrate an understanding of the various personnel who contribute to the research process. Coordinate and perform the research through cooperation and respectful communication with all members of the research team.

Interpersonal and Communication Skills

Demonstrate a commitment to research integrity including the highest ethical standards in gathering, analyzing and reporting data.

Professionalism

Goal 3. Analysis and dissemination of results of research project Resident Objectives:

ACGME Competency Goals

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Demonstrate an ability to analyze the data obtained in the research study and understand the statistical methods involved.

Systems-Based Practice

Write a manuscript to the specifications of the journal proposed for submission. Revise the manuscript based on commentary from advisory faculty. Submit the manuscript for possible publication.

Systems-Based Practice Interpersonal and Communication Skills

Present the results of your research at the year-end research symposium. Talks will be 12 minutes long with 3 minutes of Q&A. Residents are expected to present a project at the end of their R3, R4 and R5 years. Presentation at the end of the R2 year during the resident research symposium is optional.

Interpersonal and Communication Skills

Present a research project at the Bay Area Resident Research Symposium one time during your residency.

Interpersonal and Communication Skills

At the completion of the rotation, be able to reflect and describe intra/interpersonal and professional challenges and successes of the research project.

Practice-Based Learning and Improvement

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22. Appendices

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Appendix A – Conference Dates

Date Oct. 3-6, 2021

Event AAO-HNS Annual Meeting

Location Los Angeles, CA

Abstract Due 3/15 (annually)

Feb. 5-9, 2022

Association for Research in Otolaryngology (ARO) – Mid-Winter Meeting

San Jose, CA

8/2-9/1 (annually)

Jan 20-22, 2022

Triological Society: Combined Sections Meeting

San Diego, CA

7/1-8/1

April 27- May 1, 2022

Combined Otolaryngology Spring Meetings (COSM)

Dallas, TX

7/1-10/15

June 17, 2022

Stanford OHNS Residency Symposium

Stanford, CA

6/1

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Appendix B – Key Indicators Required Minimum Number of Key Indicator Procedures For Graduating Residents Note: Case logs for 2017 program graduates will be reviewed for compliance with minimum numbers but no citations will be given. Residents graduating in 2017 are expected to achieve the required minimum numbers for all Key Indicator Procedures. Achievement of the required minimum numbers is an indicator of experience but is not considered an indicator of competence. Programs should continue to evaluate procedural competence in order to ensure that graduates are competent to enter practice without direct supervision.

Category KEY INDICATOR: Head & Neck

KEY INDICATOR: Otology/Audiology

KEY INDICATOR: FPRS

KEY INDICATOR: General/Peds

Procedure Parotidectomy (all types) Neck Dissection (all types) Oral Cavity Excision Thyroid/Parathyroidectomy Tympanoplasty (all types) Mastoidectomy (all types) Stapedectomy/Ossiculoplasty Rhinoplasty Mandible/Midface Fractures Skin Flaps and Grafts Airway – Pediatric and Adult Congenital Neck Masses Ethmoidectomy Bronchoscopy

Min # 15 27 10 22 17 15 10 8 12 20 20 7 40 22

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Appendix C – Handover Evaluation Form

133

134

135

Appendix D – Evaluation Form of Faculty by Resident

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137

138

Appendix E – Evaluation Form of Resident by Faculty

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140

141

Appendix F – Evaluation Form of Service/Rotation by Resident

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143

144

Appendix G – Resident Peer Evaluation Form

145

146

147

Appendix H – Evaluation Form of Resident by Staff

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149

Appendix I – Evaluation Form of Resident by Patient

150

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Appendix J – Facial Trauma Call Policy

Craniofacial Trauma & Oral Medicine (Dental) Call Policy Stanford Hospital & Lucile Packard Children’s Hospital The Plastic Surgery Division and Otolaryngology/Head & Neck Surgery Department provides Stanford Emergency Department call coverage for Maxillofacial Trauma and Dental related problems.

1. Stanford: Otolaryngology (ENT) takes call on even days. Plastics takes call on odd days. a. SCVMC: ENT takes call on odd days. Plastics takes call on even days. b. VAPA: ENT takes call on even months. Plastics takes call on odd months.

2. Call switches at 6am at SHC. 3. Consult is assigned at the time the service is initially paged (not when the patient arrives in the ER/ICU or when the resident answers the page).

4. DAYTIME Oral Medicine & Maxillofacial Surgery Consults: The service will see all dental/OMFS consults during normal business hours (8a-5p, M-F); the plastics/ENT resident should direct referrals and calls to OMFS during this time. The smartpage schedule designates the daytime dental resident (if available) and dental attending with contact information.

5. NIGHTIME Regarding dental trauma (tooth luxations/avulsions with isolated alveolar bone fractures) or odontogenic infections: the ED should consult smart page to determine if a dental resident is on call (dental resident is on call approximately 20% of the time.) If no dental resident is on call then the designated plastic surgery or ENT resident should be paged. The back-up attending dentist will be contacted by the Plastic Surgery/ENT/Dental designated resident as needed for consultation.

6. On their designated call days, ENT or Plastics will consult for cutaneous facial infections, TMJ dislocations, and ear lacerations. Plastics may defer to ENT for facial infections that are salivary gland, sinus- or ear-related.

7. Non-surgical infection admissions may be admitted to Internal Medicine, and ENT or Plastics will follow as needed. If internal medicine will not admit the patient with an infection of dental or possible dental origin then the patient should be admitted to the ENT or Plastic surgery service who is on for craniofacial trauma/dental for that day.

8. ENT is to see all deep space infections, ear hematomas, and temporal bone trauma. If a temporal bone trauma patient has other facial trauma and Plastics is on call, then Plastics is to address the other facial trauma.

9. ENT or Plastics may repair eyelid lacerations or retain the option to consult Ophthalmology for complex eyelid lacerations.

10. Consults that can be safely managed as an outpatient: nasal fractures (open or closed), mandible fractures (without airway concern), orbital floor fractures without entrapment or vision changes, maxillary sinus fractures. If patients are admitted for another reason with these injuries they can be seen on a non-urgent basis during the day.

11. If the ER or the patient has a specific request for Plastic Surgery and it is an EVEN day (ENT); or if there is a specific request for ENT on an ODD day (plastic surgery) the resident who is called 152

can respond by indicating that the other service is on-call for facial trauma; Facial plastic surgery is included within the ENT call coverage. HOWEVER, if the ER or patient specifically requests/insists that the nature of the problem requires a specific service (even though that service is not officially on call that day) then you should be available to see the patient, regardless.

12. ORBITAL FLOOR FRACTURES: a. Days 1-10 of month: i.

For isolated orbital floor fractures (ie., no other facial trauma issues): oculoplastics will be the lead team for repair of orbit fractures- no need to involve plastics or ENT. ii.

For orbital floor fractures with other facial trauma: ENT/Plastics will be the lead team for other facial trauma and will coordinate the care of the floor fracture with Ophthalmology. In these cases, Ophthalmology will be responsible for the orbital floor fracture and any repair will be performed as a joint case. b. Days 11-month end: ENT and plastics will be the lead team on any orbit fracture with ophthalmology help to clear the globe. If there is ocular compromise (globe not cleared) the patient will be managed by Ophthalmology and the orbital floor fracture repair will be decided after the eye pathology is appropriately addressed. Orbital floor fractures should be referred to the ENT and plastics services, while Ophthalmology consults are obtained for vision and globe assessment only.

Rev April 2018

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Appendix K – Medicine/ENT/FACE/ED Inter-Service Agreement Medicine/ENT/FACE/ED Inter-Service Agreement (Effective September 2019) Admissions Patients with an ENT/FACE issue will be admitted to ENT/FACE, UNLESS the patient has one of the following medical conditions, in which case they will be admitted to a medical service: 1,2,3,4,5 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

Acute chest pain or EKG/enzyme evidence of ischemia (including troponin above upper limit of normal) Dyspnea, or signs/symptoms of pulmonary edema, or >2 liter new O2 requirement (If these signs or symptoms are due to an upper airway obstruction then admit to ENT) Decompensated Heart Failure Uncontrolled arrhythmia or new arrhythmia with persistent/recurrent HR >110 DKA Severe valve disease EF <30% on most recent ECHO Sepsis or any complicated active infections (e.g. diverticulitis or pneumonia but not bronchitis or uncomplicated UTI) Infections of the Ear/Mastoid/Nose/Throat/Epiglottis with sepsis would be admitted to ENT with medicine or ID consult if needed.

Acute kidney injury Persistent/Recurrent systolic BP >180 or diastolic >100 Persistent/Recurrent systolic BP < 90 despite appropriate fluid challenge (ICU consult recommended) Any signs of active internal bleeding (Except epistaxis alone would be admitted to ENT. Epistaxis due to hematologic disorder would be admitted to Heme.)

Acute alcohol intoxication with significant behavioral disturbance or acute alcohol withdrawal Decompensated liver disease including any of: hepatic encephalopathy, INR >1.7, new onset jaundice Focal central neurologic changes including stroke and TIA (admit to neurology) Patients currently on hospice or requiring comfort care who will be managed nonoperatively Patients in need of vulnerable adult or elder abuse evaluation

Consults Surgical Co-Management Hospitalist/Nocturnist/Medicine Resident Consult Role 1.

If the SCM hospitalist is consulted on a patient admitted to the otolaryngology service, they will see the patient within 3 hours (if called STAT within 1 hour).

2.

For patients followed by the SCM hospitalist service, the SCM hospitalist will be paged directly regarding medical issues from 8 AM-5 PM. After 5PM, the 1st page for medical issues is to the otolaryngology resident on call, who after evaluating the patient may then contact the on-call SCM hospitalist (p24311). The SCM hospitalist may contact the in house nocturnist (N1; p12012) to perform bedside evaluation/treatment as necessary. If acute medical issues will require frequent monitoring/treatment decisions then a transfer request should be considered (see below Transfer Requests).

The consulted SCM hospitalist will write daily notes and orders for evaluation and management of medical issues (e.g., labs, medications, etc.). Notes will include full risk stratification for intra-operative intervention and will recommend additional consults when appropriate.

3.

1

Admitting medical service is dependent on active medical issues (e.g., decompensated heart failure to CCU/CSU instead of general medicine) and will be determined as per the ED Admissions Grid.

2

Patients with an active issue that is more appropriate for a non-ENT/FACE/medicine service will be admitted as per the ED Admission Grid (e.g., a patient with facial cellulitis, elevated creatinine, and acute appendicitis would go to general surgery).

3

Uncertainty regarding the appropriate primary admitting team should be resolved through a discussion between the otolaryngology/medicine admitting residents. If after discussion uncertainty persists, it should be resolved through an attending to attending discussion initiated by the service initially called by the ED for admission. (ED Decides on admit service; if a different service is felt to be more appropriate then a transfer to that service can be done per the workflow in this agreement after the admit order) 4

Patients with invasive fungal sinusitis will be admitted to the medicine service with otolaryngology consulting.

5

Patients requiring direct admission after an elective otolaryngology surgery or directly from otolaryngology clinic are subject to this agreement.

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4.

5.

6.

For non-emergent medical issues that develop overnight (5pm – 7am) in patients known to the SCM hospitalist, the on call SCM hospitalist will contact the in house nocturnist to perform evaluation/treatment. If non-emergent acute medical issues will require frequent monitoring/treatment decisions than a transfer request should be considered (see below Transfer Requests).

For non-emergent after hours (5pm – 7 am) consults on patients not followed by the SCM hospitalist, the otolaryngology resident should contact the on-call medicine consult resident (p27111) who then staffs the consult with the on-call SCM hospitalist.

For emergent medical issues, the ICU fellow should be contacted directly.

Otolaryngology Consult Role

1.

If otolaryngology is consulted on a patient admitted to a medical service, they will see the patient within that day (if called STAT for an airway, they will be seen immediately).

2.

Otolaryngology consults will write daily notes and will write recommendations pertaining to evaluation of the chief concern, anesthesia evaluation, OR scheduling, NPO status, equipment orders, PT/OT, perioperative antibiotics, wound care, and activity level.

Transfer Requests From Otolaryngology to a Medical Service 1.

Patients on the otolaryngology service should be considered for transfer to a medical service if: i.

Any of the above criteria used to determine appropriate admission service develop.

ii.

Other active medical issues that supersede active otolaryngology issues that cannot be reasonably/safely managed by the SCM Hospitalist/Nocturnist develop.

2.

For non-urgent transfer requests, the decision to request transfer should be discussed with the consulted SCM hospitalist prior to the request.

3.

The on call chief medicine resident reviews/approves transfer requests to the general medicine service. Transfer requests to sub-specialty medical services (e.g., general cardiology and CCU/CSU) are reviewed/approved by the respective service attending.

From a Medical Service to Otolaryngology 1.

2.

3.

4.

Patients whose medical issues are stable should be considered for transfer to the otolaryngology service in the postoperative period.

Patients originally admitted to the otolaryngology service, who were transferred to a medical service for an active medical issue, should be considered for transfer back to the otolaryngology service after stabilization of the medical issue.

Patients transferring from the medicine service to the otolaryngology service are expected to be verbally signed out to the SCM hospitalist at the time of transfer.

For patients transferred from the ICU overnight, the nocturnist (N1; p12012) should be contacted to physically see the patient and determine stability for transfer to otolaryngology.

Emergency Department Role 1.

The Emergency department (ED) will page the appropriate admission service based on the above criteria.

2.

The ED will not determine the appropriate admission service until an adequate workup is obtained to assess for the above criteria.

3.

The service initially paged by the ED is responsible for admitting the patient if the above process has been followed

C. Kwang Sung, MD

Neera Ahuja, MD

Program Director, Otolaryngology

Medical Director, General Inpatient Medicine

Sam Shen, MD Medical Director, Adult Emergency Medicine

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Appendix L – Afterhours Outpatient Medical Advice

• PGY1s are not to take this type of call.

• Patients must receive a call back within 30 minutes of their contacting the hospital.

• If the resident does not respond or is unable to handle the call promptly (e.g., scrubbed in surgery) then the call goes to the attending physician on call (2nd call); after that the Clinic Chief/Division Chief (3rd call).

• Any medical advice given during these calls must be documented in EPIC.

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Appendix M – Paging System

Effective June 2021 1. SmartPage now shows our 3 adult floor pagers (#27082, #27083 and #27085) as separate entries.

(This should hopefully minimize the number of errant floor and consult pages going to the wrong intern.)

2. Based on resident feedback, a second Peds pager number has been added to distinguish between floor and consults.

— #25668 will remain the pager ID for floor issues and existing consults — #25670 is the new pager ID for new consults and STAT airways. This will also be the pager that gets outpatient phone calls.

The overnight resident should take the two consult pagers: #27087 for adults and #25670 for Peds — at 6:00 pm. The Peds floor pager (#25668) can remain assigned to the day team until they are ready to sign out.

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Appendix N – Verbal Orders Process Clarifications for Nurses and Physicians

Verbal Orders Process Clarifications for Nurses and Physicians (Attendings & Housestaff) Verbal orders (VOs) have an inherent degree of risk of error. While VOs are sometimes needed, it is important that the process build in safeguards to reduce risk. Optimal verbal order processes are built on mutual trust and respect between nurses and physicians. A collaborative process with built in checks and precautions is important.

VOs should be limited to urgent situations where immediate entry of orders into Epic is not feasible.

MD When to use: • Should use sound judgment about whether it is impractical (per policy) to enter order into Epic. (e.g., in a procedure, tied up in an emergency, on call out of hospital.)

• NOT for simple convenience • Explain why a VO is needed.

Remain on the phone long enough for “read back” to be completed Epic generated alerts may result in page back to clarify Verbal Orders should not be used for: • Blood transfusions (Type and hold and Massive Blood Transfusion Protocol OK) • New PCA order • Admission orders • Order sets • Chemotherapeutic agents Use safety practices when giving order: • Double ID of patient: name, MR# • All parts of drug order (name, form, dose, frequency, route, duration) • Spell out names of drugs • Say units, not abbreviations (e.g., milligrams, not mgs) • Say number digits (e.g., “fifty” becomes “Fifty - five zero”) • Avoid abbreviations (e.g., every six hours - not q6 hours) All VOs must be cosigned: • Cosign within 48 hours – best on same day

RN Will accept verbal order in good faith that there is compliance with the Hospital policy/procedure.

Always perform a “read back” Enter order into Epic as soon as possible; clarify any Epic generated questions with MD Verbal Orders should not be used for: • Blood transfusions (Type and hold, MTP OK) • New PCA order • Admission orders • Order sets • Chemotherapeutic agents Use safety practices with “read-back”: • Double ID of patient: name, MR# • All parts of drug order (name, form, dose, frequency, route, duration) • Spell out names of drugs • Say units, not abbreviation (e.g., milligrams, not mgs) • Say number digits (e.g., “fifty” becomes “fifty - five zero”) • Avoid abbreviations (e.g., every six hours - not q6 hours)

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•

Team member should sign if MD off service, or otherwise not available Education by MD leaders: • When VO appropriate • Name & SID required • Read back required • Orders not allowed as verbal • Safety practices • Cosign w/in 48 hours; same day cosign is best practice • Any member of team should cosign • Use caution to avoid errors Cosign compliance management: • Regular data reports at specialty and individual level • Physician leaders/program directors improvement strategies

Education by RN leaders: • Name & SID required • Perform read back • Orders not allowed as verbal • Safety practices • Only if immediate need • Use caution to avoid errors

Cosign compliance management: • Not RN management responsibility

V6 10/19/18 (This table does not apply to pharmacists who have their own standard work.)

These changes were created by a joint GME, nursing and physician work group with pharmacy input: Neera Ahuja, MD, Hospital Medicine Division Chief Gretchen Brown, RN, Nursing Director Janjri Desai, PharmD, Assist Dir Pharmacy Sharron Hampton, RN, Nursing Director Joe Hopkins, MD, Assoc CMO Larry Katznelson, MD, Assoc Dean GME Marc Melcher, MD, General Surgery Residency Program Director Elisa Nguyen, RN, PCM G1 – H1 Topher Sharp, MD, CMIO Julie Tisnado, RN, Nursing Director Hirut Truneh, RN, Nursing Director

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Appendix O – Temporal Bone Lab

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Appendix P – SHC Infection Control

Goals and Objectives for SHC Infection Prevention and Control Department 1. Understand and perform necessary precleaning of used ENT endoscopes prior to reprocessing by Sterile Processing Department (SPD) or disposal (https://stanfordhealthcare.policytech.com/dotNet/documents/?docid=13566) 2. Follow Stanford Healthcare Infection Prevention and Control ‘Quick Reference Guide for Infectious Diseases Conditions and Required Precautions’ when providing care to both inpatient and ambulatory care patients (https://stanfordhealthcare.policytech.com/dotNet/documents/?docid=10907)

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Appendix Q – VAPAHCS ENT Resident Handbook 2021-2022

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VA PALO ALTO HEALTHCARE SYSTEM ENT Clinic Resident Handbook - 2021-2022 Contents MUST HAVE INFORMATION ...................................................... 3 Rotation Contacts and Scheduling Details ................................. 3 Checklist PRIOR to your VA rotation: ....................................... 4 PIV Badges (personal identification verification), IE= VA Badge .......... 4 Computer Login Codes and Password ........................................ 4 ENT Office Keys........................................................... 5 Important Contacts: ...................................................... 5 Administrative Support (aka: ADPAC/PSA/Admin.) ........................... 5 CPRS helpline 650-493-5000 (dial 1, 1, then extension) ................. 5 Ordering controlled substances ........................................... 5 ENT Nursing Staff and Administrative Staff ................................. 6 SCHEDULING DETAILS ......................................................... 7 Clinic and OR Schedule ................................................... 7 H&N Tumor Board/Radiology Rounds ........................................... 9 ED/Consult Calls ........................................................... 9 SURGICAL PROTOCOLS & SCHEDULING ........................................... 10 OR Attire Guidelines .................................................... 10 OR Scheduling Procedure ................................................. 10 Admitting Floors ....................................................... 11 ENT Outlook Calendar .................................................... 12 Adding patient to Outlook OR Calendar ................................. 12 Outlook OR Calendar Color Legend ....................................... 12 Surgical Equipment Requests and Locations ............................... 13 Surgical Algorithms ..................................................... 13 VA DOCUMENTATION DETAILS .................................................. 14 Notes .................................................................... 14 Encounters ............................................................... 15 The six most important things you need to know about encounters: ...... 15 Page 1 of 30 Rev: 5-31-21

Computer Programs ....................................................... 16 CPRS (Computerized Patient Record System) ............................. 16 o

Set-up Clinic List ................................................. 16

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Set-Up ENT Note Templates .......................................... 16

VISTA Imaging Display .................................................. 17 Report or Result look-up: .............................................. 17 iMed Consent .............................................................. 17 Missing consents for procedure reminder ................................... 17 Adjuvant consults ......................................................... 18 Non-VA Consult Contacts ................................................. 19 Return to Clinic Order .................................................. 21 Dictation ................................................................. 21 DICTATION KEYPAD FUNCTIONS .............................................. 22 Coding .................................................................... 23 MRSA Procedures ........................................................... 24 CODE X - System for bleeding emergencies .................................. 24 OTHER HELPFUL COMPUTER INFO ............................................... 25 Remote Access Set-Up .................................................... 25 Printer Set-up........................................................... 26 VETERAN SUPPORT ........................................................... 27 Case Manager/Social Worker .............................................. 27 Housing & Transportation ................................................ 27 Defender’s Lodge ....................................................... 27 Fischer House .......................................................... 27 Shuttle Bus ............................................................ 27 First Day Checklist ....................................................... 28 End of Residency Checkout list ............................................ 28 VA PALO ALTO ENT CONTACT LIST ............................................. 29

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MUST HAVE INFORMATION Rotation Contacts and Scheduling Details Rotation Director: Davud Sirjani, MD, dsirjani@stanford.edu, 314-537-0242 (cell) (back up cell if it’s an emergency and he’s not picking up his cell: 314-680-5155) Attendings who need Resident clinic coverage: o Fred Baik: fbaik@stanford.edu o Jayakar Nayak: jnayak@stanford.edu o Hamed Sajjadi: hsajjadi@stanford.edu o Davud Sirjani: dsirjani@stanford.edu, o Chih-Kwang Sung: kwangs@stanford.edu Private Attendings- residents do not cover: • Bohdan Makarewycz: bohdan.makarewycz@va.gov Fellows- do not need Resident clinic coverage: Facial-Plastics – • Sarah Akkina: Important ENT Contacts: Main # 650-493-5000 (dial 1 1 ext#) Location: PAD, Bldg 100, 2nd Floor ENT Clinic. Mailstop code 112ENT ENT fax number: (650) 496-2502. If you need to send a fax, you can

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Use the Xerox machine (will need to use your PIV card) OR send from your computer if you already have an ecopy. If you do not have an ecopy, you can scan a copy using the Xerox machine. The link to efax is https://vhapalfaxrfax01/webutil/ Administrators: ENT Admin. email: v21palentadminpaloalto@va.gov Erik Nielsen: ext. 63202, erik.nielsen1@va.gov Maria Tham: ext. 66912, Maria.Tham@va.gov Surgical Onboarding Team: vhapalsuronboarding@va.gov

Charge Nurse: Ella Benadam-Lenrow: ext. 64047 Ella.Benadam-Lenrow@va.gov LVN: Crystal Vo: ext. 64046 Crystal.Vo@va.gov

Additional Required Conferences Wednesday (non-op weeks) H&N Care coordination/Rad Rounds 8:30-9:30am.

RNP: Annie Yuan: ext. 65203 Annie.Yuan@va.gov PA-C: Leslie Chan: ext. 65535 Leslie.Chan@va.gov RN: TBD: ext. 66945 Clinic rules and expectations Clinic starts promptly at 9am and 1pm Please complete inpatient rounds and workload prior to start of clinic You must leave clinic by 3:30pm on Thursdays to attend Res Ed. All documentation must be done accurately and in a timely fashion (within 24 hours) Please see PAVAPGY3andPGY5.pdf for details on specific rotation goals and objectives.

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Rev: 5-31-21

VA Checklist before you start Checklist PRIOR to your VA rotation: Otherwise you will not be able to start PIV Badges (personal identification verification), IE= VA Badge Check expiration date 1 month prior to start date o If expired, email the VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. You will need to re-do the entire registration process (i.e., fingerprinting, background check, be sponsored, make appointment with HR to get new badge, etc.) o Fingerprints are valid for 120 days. o If you have lost your badge, please contact your ENT Admin. for assistance. You will need to complete a VA Police Report before you can be sponsored for a replacement badge. o To be sponsored, you need to contact an ADPAC and your ENT Admin. can help you with this. o To make an HR appointment, go to www.va-piv.com PIV Badge PIN number o If you do not have a 6-digit PIN number associated with your PIV badge, or if you have forgotten it, contact any ENT Admin. ASAP. They can reset the pin for you. o PIN # is REQUIRED in order to prescribe narcotics (see below). Surgical Service has numerous pin re-setters who can reset your pin. Listed below are some names: Erik Nielsen: (650-493-5000, Ext. 63202, Email: Erik.Nielsen1@va.gov Maria Tham: (650 495-5000, Ext. 66912, Email: Maria.Tham@va.gov Carol Stine: (650) 858-3917, Ext. 63917, Email: Carol.Stine2@va.gov Or write to VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. and someone will get back to you.

Computer Login Codes and Password You can use your PIV card to log into the VA computer. You, as providers, also have a Windows login name- you need this to login to any computer. This starts with vhapal + part of your name. You must set up a 14-character password. o FYI. ENCRYPTION for VA EMAILS is through the use of your VA PIV card. If you have any issues with encryption, please contact any of the ENT Admins. o ENCRYPTION with Stanford email. Feel free to send encrypted emails using your Stanford email.

CPRS- VA version of electronic medical records o These (known as Verify and Access codes) were given to you when you received your badge Password MUST be updated EVERY 90 days. DO NOT LET YOUR PASSWORD EXPIRE. If you link your CPRS to your PIV badge, you can access CPRS with your PIV badge.

Please note that your VA accounts will automatically be discontinued if you do NOT use them for 180 days. If this does happen, contact ANY ENT Admin. ASAP. EXPECT a 48-hour – 10 business days delay in workflow as a request must be submitted through the Office of Information & Technology TIP! You can update password via remote access! https://citrixaccess.va.gov o Contact ENT Admin. for more information on how to get remote access.

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DICTATION CODE- to dictate Op-Reports o If you do not have one or forgot your code, contact: Ken Streibel or Ann Struck: ext. 64648 or ann.struck@va.gov TMS: When you were first boarded, you completed a couple of TMS classes that were assigned to you.

Please note that the Privacy TMS course MUST be completed ANNUALLY. This course is VERY IMPORTANT to complete. If you do not, your NETWORK ACCESS WILL BE PROMPTLY AND AUTOMATICALLY discontinued on the due date! Once you lose your access it may take up to 24 hours to restore your access after you complete the Privacy TMS. DO NOT LET THIS HAPPEN.

ENT Office Keys If you don’t have one, please contact any of the ENT Admin. ahead of time (it can take up to 2 months to get new keys). Please return all keys at the end of your residency. If you give your key to another Resident (should not do so as each key is tracked to the person the key was originally assigned to), please inform an admin. If you lose a key, there is a fine by the VA to get a replacement key.

Important Contacts: Administrative Support (aka: ADPAC/PSA/Admin.)

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BEST METHOD is to send an email to the ENT group Admin. email alias:

v21palentadminpaloalto@va.gov -

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Everyone listed below are in above mentioned group alias. So you do not need to send individual emails.

Erik Nielsen o (650) 493-5000 ext. 63202, ENT Direct line: 650-849-0264 o Email: erik.nielsen1@va.gov Maria Tham o (650) 493-5000 ext. 66912, ENT Direct line: 650-849-0264 o Email:Maria.Tham@va.gov Backup contact personnel o Write to VA Surgical Onboarding Team at vhapalsuronboarding@va.gov. and someone will get back to you.

CPRS helpline 650-493-5000 (dial 1, 1, then extension) Business hours (8:00AM – 4:30PM Monday - Friday): ext. 62777

After hours: o You can contact the AOD (ext. 60462 or ER Clerks (ext. 65470) o OR for IT related issues, call Help Desk (ext. 64767) or 1-855-673-4357

Ordering controlled substances You must use your PIV card and PIN to enter prescriptions for controlled substances (schedule 2-5). If you are unable to order controlled substance, please contact any of the ENT Admin. They can check to make sure that your access in CPRS is enabled.

If there is a problem with the ePCS program affecting the ordering of outpatient prescriptions, choose from one of the contingency plan options: Page 5 of 30 Rev: 5-31-21

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Urgently needed controlled substances (C2-5) may be handwritten on form 10-2577f and turned into the Outpatient Pharmacy for immediate filling. Outpatient Pharmacy is located in Bldg 100, 1st Floor, Room E1-100. The hours are M – F: 9AM -7PM; Weekends and Holidays: 9AM -1PM & 1:30 – 5:30PM. If you do not have your own prescription pad, you can sign one out from the Outpatient Pharmacy.

You can wait to enter all other controlled substance orders (for subsequent day pick up or mail) until the system is functioning.

ENT Nursing Staff and Administrative Staff •

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Ella Benadam-Lenrow (Charge Nurse) and Crystal Vo (LVN) o Contacts: Ella (ext. 64047), Ella.Benadam-Lenrow@va.gov Crystal (ext. 64046), Crystal.Vo@va.gov ENT RN - TBD o Information to ask: Urgent/Specific ENT or OSS appointment scheduling Post-op follow-ups or ED consult follow up scheduling Post-op/Clinic visits/Consult planning Defender’s Lodge consult needs to be made Location of ENT supplies How to setup CPRS Patient who need imaging appointments or numbers Leslie Chan, PA o Contact: (ext. 65535), leslie.chan@va.gov o Will manage all NON- Cancer cases for Dr. Nayak, Dr. Sajjadi, Dr. Sung o Staffs Dr. Nayak’s, Dr. Sung’s, and Dr. Sajjadi’s clinics o Prepare Navigation CD for sinus cases o Non-Cancer patients: pathology/imaging follow-ups, medical clearances Annie Yuan (RNP) o Contact: (ext. 65203), Pager 11671, Annie.Yuan@va.gov o Manages all Cancer cases for Dr. Baik, Dr. Sirjani, Dr. Sung o Staffs Dr. Baik and Dr. Sirjani’s clinic and NP Clinics (Op-Wed, Fridays) o Cancer patients: pathology/imaging follow-ups, medical clearances o Coordinate TB patients Administrative Staff: Erik Nielsen (or ENT Admin. Maria etc) o Contacts: write to v21palentadminpaloalto@va.gov o Enters all OR Cases in VISTA o Should be alerted when ANY changes are made to OR schedule o Call-schedule o Schedules ENT Preop/OSS appointments o Submits Pink Slips to OR o Information to ask How to setup CPRS templates Patient who need imaging numbers Page 6 of 30

Rev: 5-31-21

SCHEDULING DETAILS Clinic and OR Schedule Time AM 0800-1200

Monday- 8:30am Minor Proc: PGY 3>5 Baik Clinic: PGY 5>3, NP

NON-OPERATIVE WEEK (starting 7/1/21) Tuesday- 8:30am Wednesday- 8:30am Sirjani Clinic: PGY 3, 5, NP Tumor Board (8:30-9:30am)

FP clinic

PM 1200-1700

Nayak Clinic (9:00): PGY 3, 5, PA

Baik Clinic: PGY 3,5, NP

Sirjani Clinic: PGY 3, 5, NP, R

Nayak Clinic: PGY 3, 5, R, PA

FP Clinic

Thursday- 7am **OR- Sajjadi: PGY 3 or 5

Friday- 7am **OR- Baik/Sirjani PGY3,5

Sung Minor Procedures: PGY 3 or 5, PA

RNP clinic (AY)

OR- Sung PGY 3 or 5

**OR- Baik/Sirjani PGY 3, 5

Sajjadi Clinic: PGY 3 or 5, R, PA

R: Research Resident Time AM 0800-1200

**1 resident to scrub out for pre-ops OPERATIVE WEEK (starting 7/8/21) Monday -8am Tuesday- 8:30am Wednesday- 7am OR- FP: PGY 3 or 5 Sirjani Clinic: Tumor Board (8:30— PGY 3, 5, NP 9:30am) Baik Clinic: PGY 3 or 5, NP OR- Nayak: PGY 3, 5

Thursday- 7am **OR- Sajjadi: PGY 3 or 5

Friday- 7am **2 ORs- Baik/Sirjani APP clinic (LC)

Sung Clinic/Minor Procedures: PGY 3 or 5, PA

0900 Sung Clinic: R, PA PM 1200-1700

OR- FP: PGY 3 or 5

Sirjani Clinic: PGY 3, 5, R, NP

Baik Clinic: PGY 3 or 5, NP

R: Research Resident

OR- Nayak PGY 3, 5

OR- Sung PGY 3 of 5

Sung Clinic: R, PA

Sajjadi Clinic- JS, PGY3 or 5, R, PA

**2 ORs- Baik/Sirjani

**1 resident to scrub out for pre-ops Page 7 of 30

Rev: 5-31-21

Additional Notes: • Monday OPERATIVE WEEK: check-in patient at 8AM, case starts at 9AM • All other OPERATIVE WEEK: check-in patient in at 7AM, case starts at 8AM • ALL PATIENTS: Surgical site MUST be marked, even bilateral or midline cases need a wrist band stating the procedure to be done.

RESEARCH RESIDENT (R: RESEARCH RESIDENT) • If clinic needs extra-help from Research resident, please give those dates in advance. o Per Messner, Research Resident must have at least 2.5 days of research time per week on average.

• During PGY3 or PGY5’s vacation/conference/interview period, Research resident usually works as full time • Check to see if help is needed for Monday procedures in Baik clinic the week before.

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H&N Tumor Board/Radiology Rounds • •

When: Wednesday Every week: Virtual on Teams 8:30-9:00am Annie will manage the list

ED/Consult Calls •

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ENT covers facial trauma (including TMJ) on EVEN months o ENT for Even months o Plastics on Odd months Staffing: o Day consults staffed with attending who is in-house that day o Night consults staffed with on-call attending Ask the person to place “consult to ENT” for us to write a consult note Rehab/TBI/Spinal cord unit consults: do not delay or ignore the consults. YOU MUST SEE THOSE CONSULTS NO MATTER WHAT! Please be courteous.

Dental: Vet is only eligible if: 1- it is an emergency, 2- if treatment is related to H&N Cancer, or 3- 100% service connected o H&N Cancer related- place consult under “Dental Adjunct Medical Need Outpatient”. o Dental DOES NOT provide dentures or prosthetics. This is all out of pocket for the patient. EVEN if the defect is related to H&N cancer or our surgery. Dental will only do the BARE minimum to get them ready for XRT or surgery. They extract teeth but do not replace. Please make sure the patients know this ahead of time.

Usually patient can come to clinic if they are safe to transfer to clinic For Night Consult ENT Resident: Please do not tell ED that Patient should come to ENT clinic at 8 or 9AM next day. Sometimes there is no clinic especially if it is an Operation week (Two ORs going at the same time on Friday). If patient needs to be seen urgently in the clinic at night, get the phone number of the patient and tell the ED that our clinic will contact the patient next morning and will see the patient next day (AM or PM). And please send the email to the VA ENT team (v21palentadminpaloalto@va.gov) and our Clinic nurses; Ella and Crystal. Ella.BenadamLenrow@va.gov or Crystal.Vo@va.gov

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SURGICAL PROTOCOLS & SCHEDULING OR Attire Guidelines Please note the following regarding Operating Room attire: • Scrubs and hats worn during dirty or contaminated cases should be changed prior to subsequent cases even if not visibly soiled.

• Operating room (OR) scrubs should not be worn in the hospital facility outside of the OR area without a clean lab coat or appropriate cover up over them.

• OR scrubs should not be worn at any time outside of the hospital perimeter.

• OR scrubs should be changed at least daily.

• Like OR scrubs, cloth skull caps should be cleaned and changed daily.

The American College of Surgeons statement on OR attire guidelines https://www.facs.org/aboutacs/statements/87-surgical-attire also supports the items above.

OR Scheduling Procedure Below are steps to take for OR scheduling once patient is deemed a surgical candidate 1. Fill out OR Booking Sheet completely (and legibly!). This sheet is in every exam room and Resident rooms a. Any changes to OR schedule, you must email the entire ENT Team v21palentadminpaloalto@va.gov b. CANCER CASES: OR Booking sheet given to Annie c. NON-CANCER CASES: OR Booking sheet given to Leslie 2. Resident, Attending, and patient should agree on surgery date together. Look in OUTLOOK ENT OR calendar (if you need access to this calendar, contact Erik and/or Maria). Check with RNP/PA/RN if you are unsure about availability. a. SINUS CASES: Do not schedule OR date unless you have followed the algorithm and cleared the date with PA first.

3. Scheduling OR date on same clinic visit day: a. Surgery within 30 days of clinic visit, these elements must be completed: i. ENT Pre-op and H&P appointment (valid for 30 days) ii. Consent (obtained during ENT Pre-op appointment, valid for 60 days) iii. Anesthesia (OSS) appointment (preoperative medical clearance) iv. Any other medical clearances, lab work, and x-rays b. Surgery less than 72 hours: i. URGENT CASES need a “Request to Add-On” slip (aka PINK SLIP; see OR Pink SlipRequest to Add-On Form-Orginal.docx found in the Resident Handbook Folder within the ENT S drive) ii. Look into OUTLOOK OR Calendar and coordinate with RNP/PA to schedule (talk to Ella if RNP/PA not available) iii. Turn copy of PINK SLIP in person to OR (Building 100, 3rd fl., E3-100) iv. For any OR communication during work hours, please let either Leslie or Annie know of any add-ons or changes (i.e pink slips). v. After hour pink-slips or OR add-ons, you can communicate directly with the OR.

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4. Scheduling OR date on another date: a. If more than 72 hours: i. ENT RN/RNP/PA will notify patient once surgery is scheduled ii. Confirmed ENT Pre-op and OSS appointments iii. Surgery package sent 1. Contains surgery letter, surgeons credentialing information, any relevant information 2. FYI that credential information is also available online 5. FOR COMPLEX OR CASES: email OR team and Attending the plan the day prior to surgery a. Searcy, Nancy <Nancy.Searcy@va.gov>; Yanokodani, Colleen E. <Colleen.Yanokodani@va.gov>; Chan, Leslie C. <Leslie.Chan@va.gov>; Annie Yuan Annie.Yuan@va.gov Admitting Floors • 23-hour Observation: EDOU (emergency department obs unit)- 1st floor, back of ED o only if they will be here <23 hours; no discharge summaries necessary o 4 beds available o For patients who take shuttle or don’t have driver • 47-hour observation: beds available on 3C/2A/4C1 o Only if they will be here <48 hours; no d/c summaries necessary o 3C- +tele and +continuous pulse oximetry, q4h monitoring o 2A- +tele and +continuous pulse oximetry, q8h monitoring o 4C1- medicine room, no TELE, no continuous pulse ox, q8h monitoring • 3C: Surgical Floor, 1:5-6 ratio, o +continuous pulse oximetry monitoring (up to 10 beds) o +telemetry (up to 8 beds) o Q4h monitoring • 3C-SDU: 1:4 ratio, 4 PRIVATE rooms close to nurses’ station o Would NOT recommend for someone who needs close monitoring o +Telemetry, +continuous O2 monitoring o + trach care or patients who just comes out of ICU o q2h suctioning • IICU: Can use as female SDU (as female usually cannot go SDU at 3C) o less acute than MSICU o q1h suctioning • MSICU: o Free flap or Acute airway issues • 4C: o Usually medicine primary/Acute Rehab. Usually send patient who requires long hospital stays ex IV ABX, palliative care etc.

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ENT Outlook Calendar •

Surgeries, minor procedures, and staff schedules are posted here. If you need access, contact any ENT Admin. (Calendar needs to be shared from the Sensitive Surgical Sharepoint and then connected to Outlook.)

Adding patient to Outlook OR Calendar Below are the steps to take to input a patient into the ENT shared Outlook calendar for surgeries. Usually one of the RN/RNP/PA will do this once they receive a completed OR Booking Sheet.

1. Go to OUTLOOK Calendar 2. Go to “HOME” Tab click on “NEW APPOINTMENT” a. Subject Line: Last Name, First name, Last 4 SSN#, Attending, Surgery Procedure(s), Post-Op Admission Status b. Location line: Enter Diagnosis c. Start Time: Surgery date and surgery start time d. End Time: Surgery date and surgery end time e. Body: i. In OUTLOOK OR Calendar double click “NONOPERATIVE WEEK” or “OPERATIVE WEEK.” It will ask you if you want to open the recurrence or the series. Click “OK”, then copy and paste into new appointment. Fill out all respective fields.

3. Click on “CATEGORIZE” button and click Purple Category Outlook OR Calendar Color Legend Below is the color-coding system for the OUTLOOK OR Calendar and the elements they include in order to be that color • Light Green o Surgery placeholder; date usually not confirmed with patient and/or RN/RNP/PA coordinator • Blue o In-Clinic Procedure that Ella and Crystal handle • Purple o Surgery date determined o OR booking sheet filled out completely, and case is ready to be entered Vista. Person inputting patient information changes to purple (usually Annie/Leslie).

• Yellow o Admin. has submitted the OR booking sheet into VISTA Package. Admin. changes to yellow • Green o ENT Preop/OSS appointments complete, consent complete, labs and imaging complete, and medical clearance obtained. Chief Resident changes to green before surgery.

• Red o Cancelled surgery cases

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Surgical Equipment Requests and Locations All surgical equipment and tools should be requested via the Surgical Request Form (AKA OR Booking Sheet) that is completed for all cases. These sheets are located in many rooms in the ENT clinic. Please circle the equipment needed and write in anything that is not already listed. Admin., then enters the request into CPRS, and Colleen Yanokodani, RN, in OR (Bldg 100, 3rd Fl., Room F3-102) makes sure that the equipment is brought to the operating room from the various surgical storage areas upstairs (P&P room, Omnicells in old holding area, C locker, etc.). If you need something while in the OR, you can ask the circulating nurse to get it for you.

If there is something that you want to use that we normally do not stock, be prepared to wait at least 2 months, if not more. The VA has a specific request process that needs to be followed, and you need to talk to Colleen.

The attending will need to complete and submit an Operating Room Procurement Committee Request Form (AKA the “gold form”) and begin the process of procuring the new equipment. This can take anywhere between 2 months and 1 year. Click the link (OR Request form (gold form).pdf) to see for an example of the gold form.

Maria Tham can also provide you with more information.

Surgical Algorithms Due to backlogs with surgery date availability, we are creating algorithms based on standards of care to simplify when a patient is a candidate for surgery. Currently, we have one algorithm completed for sinus surgery scheduling. The algorithm can be found in the document entitled “Sinus Scheduling algorithm.” Please contact RNP/PA/RN for more information.

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VA DOCUMENTATION DETAILS The VA has an online Physician Reference Guide that contains everything you need to know about CPRS, the computer system used to document patient care. To access it from the Intranet, go to the VA home page (https://vaww.paloalto.va.gov), then under the Patient Care tab, choose CPRS Physician Reference Guide.

The CPRS team also created videos that you can review. Please click on below link.

Residents: Videos 1 – 11; Approximate Time: 90 Minutes https://dvagov.sharepoint.com/sites/PALClinfo/CPRS%20Training/Forms/All%20Documents.aspx?RootFolder=/s ites/PALClinfo/CPRS%20Training/CPRS%20Training%20Videos%202020&FolderCTID=0x01200018288C6F6A023E 42BC5A0FF8BF6495CD&View=%7b37420F91-60C7-456D-BA14-4E8F3C287354%7d

Notes Create documentation by using the notes tab in CPRS, then “new note”. You can then go to the template tab and select a template from the “ENT” section through “Shared templates” • •

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Admission H&P: within 24hr of admission Preop H&P: 30 days prior to procedure – Must contain 1. Diagnosis 2. PE findings (including Lung and Heart) 3. Procedure to be performed 4. Alternate treatment plans discussed 5. DC/anticoagulation Updated Pre-op: Within 24hours of surgery (By Attending) – Must contain 1. No changes in condition 2. Proceed with scheduled operation Brief OP NOTE: Before patient changes level of care (Before leaves the OR) OP report: You can either dictate or write (if you write then you cannot go and edit: have to write just once, that’s it) Discharge summary: Entered or dictated within 24hrs to DC

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Life-Sustaining Treatment – used to document CODE status (if not a full code, orders are entered) POLST

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Informed Consent: 60days of surgery

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Encounters Every note you write must be accompanied by an ENCOUNTER in order for ENT to get payment/credit for the visit, whether that visit is in-patient, in the ED, or in clinic. There are 2 ways to enter an encounter: 1. select ENCOUNTER in CPR or 2. right-click while writing your note and select “Edit Encounter information.”

The six most important things you need to know about encounters: 1) Attendings must be selected as “Primary Provider.” Residents are not primary providers.

2) In the “Visit related to” box, you must choose YES or NO if the issue is service connected. If you are not sure, click on the patient’s name in CPRS to pull up the “patient inquiry box.” It will tell you if a condition is service related.

3) You must complete the diagnosis and procedure tabs 4) If the note is a consult, please link the note to the consult 5) For inpatients who are being seen in the ENT clinic and have a scheduled appt, change the “clinic” location to reflect that you are seeing them in the ENT clinic 6) For patients you are seeing as a consult in the ED or on the unit, in order for ENT to get credit for it, first make sure the consulting team places an ENT CONSULT, then: Clinic location box new visit tab ENT-STAFF (PAD) start new consult note like in #5 For more details about entering encounters, please ENT encounters details.docx.

For more details about Evaluation and Management Coding Guidelines, please see Evaluation & Management Coding Guidelines 1995.docx and Time Based Coding Guidelines.docx, both found in the Resident Handbook folder within the ENT folder of the S drive.

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Computer Programs There are 3 main computer programs you need to know about for patient care.

CPRS (Computerized Patient Record System) Main program for all patient notes, imaging reports, etc. See also the previous page on VA Documentation. o Finding a patient: Entering First initial of last name and last 4 of SSN# Find through floor or clinic (i.e., PAD-ENT-SIRJANI) o Entering notes and encounters for each clinic visit Inputting type of visit, diagnosis, procedures, etc. o Inpatient/Outpatient ordering on left side menu o Inpatients going to OR Helpful to select all current orders and enter them in as delayed orders before the case o Consult requests Consults to other services, palliative care, transfer to 4C, Defender’s Lodge, nonformulary medications, speech, physical therapy, radiation therapy, oncology, etc.

See next page for how to enter specific consults o Set-up Clinic List Reason: list of patients for the current day and clinic automatically populates Steps: • 1. Select “zztest,Andrew” patient • 2. Select TOOLS tab, scroll down and select OPTIONS o Select LIST/TEAMS tab, select PATIENT SELECTION DEFAULTS Under LIST SOURCE, select COMBINATION Under SORT ORDER, select either ALPHABETICAL or APPOINTMENT DATE (depending on your preference) o Select SOURCE COMBINATIONS Select source by • CLINIC and select and ADD all ENT specific clinics that you staff o I.e. (PAD-ENT-BAIK, PAD-ENT-NAYAK, PAD-ENTNEW-SUNG, PAD-ENT-SAJJADI, PAD-ENT-SIRJANI, PAD-ENT-SUNG, PAD-ENT-SUNG-PROCEDURE, PADENT-STAFF) • SPECIALTY and select and ADD all ENT specific Wards o I.e. (ENT-IICU, ENT-OBS, ENT-SMICU, ENT-WARD) o Select NOTES tab, select DOCUMENT TITLES Search Document Titles starting with ENT and select and ADD all titled notes that are appropriate for your work • 3. Click OK to save everything o Set-Up ENT Note Templates Steps: • 1. Select “zztest,Andrew” patient • 2. Select NOTES tab, select TEMPLATES • 3. Right click SHARED FOLDER, scroll down and select EDIT TEMPLATES • 4. Expand SHARED FOLDER in Shared Templates area, scroll down and click on ENT Folder and click on RIGHT ARROW to copy to my templates • 5. Select OK to save everything

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VISTA Imaging Display o Reason: Useful for audiograms or photos of patients. Access through CPRS, click on TOOLS tab, scroll down and select VISTA Imaging Display o If you are unable to view images through Vista Imaging Display, please contact any ENT Admin. They will check your access. o To look at images: Go to CPRS, click TOOLS, scroll down and click on RADIOLOGY(INTELLISPACE/PAL-STENTOR) and select either PAD for PAD images or Other Sites for other sites You can also access Intellispace through the desktop. Currently, access is through the VA PIV card. If you cannot access Intellispace, please contact any ENT Admin.

Report or Result look-up: Joint Legacy Viewer (JLV), Labs, Predefined Lab Worksheet, Clinical Reports • Must click on blue “Remote Data” in upper right corner of CPRS to pull in Data from Other VAs • PICIS – flowsheet for ICUs Need to access via Tools>Specialty Applications> PICIS Remote Application Change to Option to “RDP”: Use Window’s username (vhapal…) & PIV card password • Vista Imaging (used mostly for ECGs, procedure documentation, advance directives, IMED Consents, etc.)

• Joint Legacy Viewer (JLV) -- used for most current outpatient meds for patients from other sites: SharePoint Resource: https://dvagov.sharepoint.com/sites/VACOVE2/JLV/Resources/Forms/AllItems.aspx?viewpath=%2F sites%2FVACOVE2%2FJLV%2FResources%2FForms%2FAllItems.aspx

iMed Consent o Defined: Digital consent platform. o All procedures require an electronic informed consent documented in the medical record o Access through CPRS, click on TOOLS tab, scroll down and select iMed Consent and follow instructions. Include any Attending that may be participating in the case. o There have been many issues with access with IMED CONSENT due to software upgrades. If you have any issues accessing your IMED Consent, please contact any ENT Admin. to resolve for you. o If the electronic consent is not working, you can fill out a hardcopy with signature and request an Admin. to upload it to Vista Imaging in CPRS.

Missing consents for procedure reminder This is a reminder that almost anything you do that require an injection needs a consent (and a minor procedure note because it has certain required wording on that document i.e. timeout was done, consent obtained, etc. etc.).

The only thing(s) so far that doesn’t require consent are: • Scope exams • Sinus debridements (though this is somewhat arguable… safe to just get consent) • Treatment of epistaxis • Drain/suture/staple removal

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Adjuvant consults 1. Dental a. To place the dental consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “dental” (“dental adjunct to medical need outpatient” will populate), hit ENTER iv. Select “head and neck cancer care” v. Submit order (must be signed) 2. Radiation a. To place the radiation consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “Community care – Radiation therapy” and hit ENTER iv. Justification for Community Care-Radiation Therapy: VA does not provide v. Type: choose “Evaluation and Treatment” vi. Enter relevant information 1. Please paste into consult: initial eval + 1 office visit before treatment, diagnostic tests, tx, post tx follow-up visits x4 over 12 months from date of initial eval. vii. Most radiation consults go to Stanford viii. Submit order 3. Oncology a. To place the oncology consult in CPRS: i. Choose New consult ii. choose last ENT clinic cancer visit (Sirjani, Sung, Baik) iii. under “consult to service” type “oncology” and then choose the correct service and location iv. Choose e-consult or Face-to-face 4. Cancer Survivorship Care plan (see below for details) a. To place a cancer survivorship consult in CPRS: i. Choose New consult choose last ENT clinic oncology visit (Sirjani, Sung, Baik) under “consult to service” type “cancer” (“cancer survivorship/PAD Outpt” will populate), hit ENTER ii. Fill in the associated fields (Cancer diagnosis, date of diagnosis, Date of last treatment) iii. Under “reason”, check “survivorship care plan.”

The American College of Surgeons Commission on Cancer requires accredited programs like VA Palo Alto to implement treatment summaries and survivorship care plans to help improve communication, quality, and coordination of care for cancer survivors. The timing of delivery of the survivorship care plans is within one year of the diagnosis of cancer and no later than six months after completion of adjuvant therapy (other than longterm hormonal therapy). The “one year from diagnosis” requirement to have a care plan delivered is extended to 18 months for patients receiving long-term hormonal therapy. Care plans are given to patients Stages I-III who are treated with curative intent.

We are asking providers to place a survivorship consult on the date of the patient’s last chemotherapy or radiation treatment. For those patients who only get surgery as treatment, the survivorship consult can be placed on the day you see the patient back for his/her first follow up visit. The consult will alert Lakedia Bank (Oncology RNP) and they will either complete the care plan or provide assistance to the various departments on how to complete the care plan.

The Accreditation Committee made the following changes to the established time frame and scope of implementation.

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January 1, 2015 – implementation of pilot survivorship care plan process involving 10% of eligible patients.

January 1, 2016 – Provide survivorship care plans to 25% of eligible patients.

January 1, 2017 – Provide survivorship care plans to 50% of eligible patients.

January 1, 2018 – Provide survivorship care plans to 75% of eligible patients.

January 1, 2019 – Provide survivorship care plans to all eligible patients.

For more information about the care plans, contact Lakedia Banks at x65848/64169.

Non-VA Consult Contacts Allergy consults ENT clinic, Stanford 801 Welch Rd. Stanford, CA 94304 Ph 650-725-3009 (Lily) fx 650-725-6685 Please fax authorization to: Sarita (650) 736-2589

RAD ONC Stanford consults (preferred) Radiation Oncology Stanford Name of Provider: Quynh Le 875 Blake Wilbur Dr Clinic D Stanford, ca # (650) 723-6171 FAX: (650) 725-8231 Please paste into consult: initial eval + 1 office visit before treatment, diagnostic tests, tx, post tx follow-up visits x4 over 12 months from date of initial eval.

RAD ONC Turlock consults Stanford Emanuel Radiation Oncology Center 800 E. Tuolumne Rd Suite 101 Turlock, CA 95382 Phone: 209-664-5030

Community Hospital of the Monterey Peninsula Dr. Tamler and Dr. Holley Radiation Oncology 23625 Holman Hwy. Monterey, CA 93940 Phone: 831-625-4630 Fax: 831-625-4635 Santa Cruz Radiation Oncology Medical Group

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Dr. Meisel 1575 Soquel Dr. Santa Cruz, California 95065 Phone: (831) 462-3050 Fax: (831) 462-6068 Stanford Otology: Stanford Ear Institute 2452 Watson Ct Palo Alto, CA 94303 (650) 723-5281 Fax: (650) 725-8502

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Return to Clinic Order All follow-up appointments need to be entered into CPRS as a “return to clinic” order.

Three (3) Month Follow-up Rule: • Within 3 months: o Enter order for appropriate Attending clinic and time frame E.g. +6w (for 6 weeks) or +2m(for 2 months) • After 3 months: o Place into recall. Recall is a waitlist. o No appointment will be made, and patients will be mailed a postcard 2 weeks prior to intended appointment o If patient in recall and needs imaging prior to their 1-year follow-up, please note in special instructions E.g Patient to schedule MRI prior to ENT appointment o CANCER PATIENTS DO NOT GO INTO RECALL In special instructions, write “NO RECALL” and state reason • Reason example: Cancer surveillance, needs MRI/audio/PETCT arranged at the same time

Dictation 1. Dial 800-394-3845.

When the call is answered, you will be greeted with a voice prompt which gives you instructions.

2. Enter your USER ID, followed by the # key.

3. When prompted, key in the patient’s full 9-digit SS number, followed by the # key.

3. When prompted, key in Work Type, followed by # key.

WORK TYPES WORK TYPE

REPORT

WORK TYPE

REPORT

30 31

ADMISSION H&P DISCHARGE SUMMARY

40 41

EEG/EMG NUCLEAR MED

32 33 34 35 36 37 38

OPERATIVE REPORT COMPENSATION & PENSION PROGRESS NOTE VASCULAR LAB EMERGENCY ROOM NOTE STAT DISCHARGE/TRANSFER CARDIAC CATH

42 44 45 50 62 75

PULM SLEEP STUDY LETTER RADIOLOGY CONSULT STAT PROGRESS NOTE PATHOLOGY

39

GI PROCEDURE

4. At the sound of the tone, please begin your dictation.

*** THE FOLLOWING MUST BE DICTATED DURING THE BEGINNING OF DICTATION*** • IDENTIFY PATIENT NAME (SPELL THE LAST NAME AND FIRST NAME).

• ENTER FULL SOCIAL SECURITY NUMBER Page 21 of 30 Rev: 5-31-21

• • •

CLINIC SPECIALTY TITLE (ORTHOPEDIC CONSULT, ORTHOPEDIC ORTHOPEDIC PROGRESS NOTE) DATE/TIME OF SCHEDULED APPOINTMENT NAME OF CO-SIGNATURE (ATTENDING) IF APPROPRIATE.

ATTENDING,

5. If you wish to dictate multiple reports, press ‘8’ to end one and begin another.

6. To obtain a job number for the report you just dictated, press ## before hanging up. KEEP THIS NUMBER UNTIL THE DICTATION IS AVAILABLE FOR ELECTRONIC SIGNATURE. 7. To disconnect, simply hang up.

DICTATION KEYPAD FUNCTIONS PRESS 1 To pause dictation.

2 To resume dictating after pausing.

3 Rewind – rewinds approximately 3 seconds. Press ‘2’ to resume dictating.

8 To end current report & begin another ## To get job number of report just dictated before hanging up To disconnect, simply hang up.

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Coding If there are multiple surgeons scrubbed from the same service, the operative report must reflect the role of each person in the operative report to get the RVU credits. Please dictate accordingly: Please look at these definitions below and dictate accordingly.

Modifier 80

81

82

62

Definition Assistant Surgeon • Provides full assistance to the primary surgeon • Capable of taking over the surgery should the primary surgeon become incapacitated.

• If an assistant surgeon assists a primary surgeon and is present for the entire operation, or a substantial portion of the operation, then the assisting physician reports the same surgical procedure as the operating surgeon.

• The surgeon is required to specify in the body of the operative report what the assistant does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report.

• It may be helpful to mention in the indications paragraph why there is a need for an assistant.

• Only one operative report is required.

Minimum Assistant Surgeon • An assistant who does not participate in the entire procedure but provides minimal assistance to the primary surgeon.

• The surgeon is required to specify in the body of the operative report what the assistant does. It is not sufficient evidence of participation to list the assistant’s name in the heading of the operative report.

• It is a good idea to mention in the indications paragraph why there is a need for an assistant.

• Only one operative report is required.

Assistant Surgeon (When Qualified Resident Surgeon is not Available) • Used primarily in teaching hospitals to indicate that a qualified resident surgeon is unavailable.

Two Surgeons with Different Skill Sets • Each provider should document their own portion of the procedure.

• Two separate operative reports.

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MRSA Procedures Asymptomatic surgical patients with a positive swab are not required to be treated for MRSA unless they have an active MRSA infection, such as our cancer patient going for surgery on Friday. Then the recommended protocol is to collaborate with infectious disease (ID) to make sure that the Vancomycin (or other abx) blood levels remain between peak and trough and that any other required measures are taken. (This is something that needs to go into the resident handbook, so the residents are aware to coordinate with ID pre-op.)

Patients with a positive MRSA swab are on contact precautions while in-patient, but they are not kept isolated, i.e., they can still go down to get a cup of coffee from Starbucks. (Yes, you’re right, not logical.)

Asymptomatic veterans who are out-patient are not monitored or followed.

There is some controversy about the benefits of completing the nares swabs. Some hospitals no longer do them, since MRSA is now considered a “normal” part of most people’s microbiome.

CODE X - System for bleeding emergencies In collaboration with nursing, VA has now developed a new system for bleeding emergencies that need to go to the OR off hours. When the nursing supervisor is called to get the OR team in, you/your resident-fellow needs to tell them it is a CODE X situation. This means that the nursing supervisor will call in 3 nurses to have adequate staff in the OR and arrange for extra resources such as blood runners. It is also a sign that the Massive transfusion Protocol should have been activated. If you think you require the cell saver or bypass machine please make sure to also have them call in a perfusionist. This status will be communicated to all of the nurses as they are called so they know they are coming into a critical situation and get set up ASAP.

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OTHER HELPFUL COMPUTER INFO Remote Access Set-Up To obtain a Remote Access Account use this link: https://vaww.ramp.vansoc.va.gov/SelfService/ • (ONLY accessible within the VA network. YOU CAN ONLY PUT IN A REMOTE ACCESS request on a VA networked computer). You will be notified (by VA outlook email and/or the email you enter) when your account has been approved and activated. o Justification for Remote Access: Provide clinical care, need to be on-call, and require remote access. Work in a sterile environment o Supervisor: Mehgan Sobejana • If you are unable to be onsite to put in this request, please contact your ENT Admin. (v21palentadmin paloalto@va.gov ) or someone from the Surgical onboarding team for assistance (vhapalsuronboarding@va.gov) • Access remote access using the follow link: https://citrixaccess.va.gov • If you have any further questions regarding Citrix Remote Access and associated resources, please contact the VA Service Desk/Help Desk (ext. 64767) or 1-855-673-4357 • If you are using your PIV card, you will need a PIV card reader. Ask your Admin for one.

• If you will be accessing with Mobile Pass, contact an ENT Admin. for details.

• Please remember that you must use your remote access at least once every 90 days. If you do not, your remote access will automatically be disconnected, and you will need to apply again.

• For a copy of the VA Remote Access “handbook,” contact any of the ENT Admins. It is also located on the ENT drive, which you have access to. S:\ENT\--Resident Handbook--

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Printer Set-up To set up: 1. Right click on the start button which is this symbol in Windows 10.

2. A window will open up. Click on RUN. (If you still have Windows 7, click on Start symbol)

3. When below screen shows up, type the below listed printer link in the blank field next to OPEN.

a. For the “Baby” Ricoh in the ENT/EYE HALLWAY (near Annie area), type in the Open box the following and hit OK. It will start connecting and you are done. \\vhapalprtom01\pal-dp183971

b. For the Xerox in the clinic wait room (near Cece), type in the Open box the following and hit OK. It will start connecting and you are done. \\vhapalappom01\pal-dp194511

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VETERAN SUPPORT Case Manager/Social Worker •

•

•

Michelle Seli RN 62781, Case Manager o located in 3C- This person helps arrange all needed outpt care for post-op pts including placement, IV abx, trach supplies, etc. Sometime PGY3 gets pages every 5mins from CM. Try to build a good relationship with CM even though sometimes CM sends a lot of pages… Eventually CM is helping us for dispo. Giving them an early head-up is also important about what should be done and plans for each patient, just like talking to Crista at Stanford C2.

Elizabeth Enriquez, MSW x67870, #11596 – Social worker for Inpatient ENT o Located in 3C- requires a consult o Helps with any social issues, complicated dispos, and advanced directives Martha Cutcomb, MSW x63967 and Rosalind Bowler MSW x65649 (Wednesdays only) x-Social Worker for Outpatient ENT

Housing & Transportation Defender’s Lodge o Criteria for requesting Defender’s Lodge Consult: Veteran is traveling 50> miles away Veteran has significant travel difficulties o Veteran usually needs a driver with them o Note that there has been numerous policy changes due to COVID-19. Double check with any ENT staff. o Entering consult Click “CONSULT” tab, click “NEW CONSULT, select own name and clinic appointment Enter “DEFENDER’S LODGE” in Consult to Service/Specialty Fischer House o Housing for family and not Veteran/patient, has to be inpatient >3days, i.e., when patient is admitted for chemo/XRT, or prolonged hospitalization Shuttle Bus o o

Click link for Shuttle bus schedule: https://www.paloalto.va.gov/shuttleschedule.asp SHUTTLE BUS DOES NOT TAKE ANY PATIENTS AFTER GENERAL ANESTHESIA. LOCAL is fine but not GETA. So those patients can go to Defender’s Lodge if they have a significant other or family member with them, if not we have to admit as Observation at C3 or EDOU.

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First Day Checklist On first day of rotation: • Window’s sign-in • PIV card encryption • CPRS sign-in • IntelliSpace sign-in • PIV PIN to order narcotics • Put in your away dates in our calendar and confirm on-call schedules Set-up: • • • • • • •

Scrub card Clinic keys Dictation code ENT Admin. to add you to Outlook calendar Set-up printer Remote access CPRS: set note titles, clinics and templates

End of Residency Checkout list At the end of your residency, please make an appointment with an ENT Admin to check out. These are the items you should bring 1. PIV Card 2. Clinic keys 3. VA sponsored electronics if any 4. ScrubX card 5. Any other item provided to you by the VA Please do not turn in items and sign out until you have completed all of your on-call duties. Please remember to complete and sign any outstanding notes/consults/encounters BEFORE YOU LEAVE.

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VA PALO ALTO ENT CONTACT LIST PAD 3801 MIRANDA AVE, PALO ALTO CA 94304 T: 650-849-0264 or (650) 493-5000 Ext 60264 ENT Mailcode: 112ENT ENT/EYE FAX: (650) 496-2502 ENT mainline (thru operator): 63924, 65751 ENT mainline: 60264 PAD=56: SJC=57: MOD=54: MPD=52 To PAGE, go to or dial 65970 (live operator will connect https://smartpage.stanford.edu/ you)

Last

First

Ext:

Pager Room #

email adress (preferred)

Akkina* Baik*

Sarah Fred

61122 E2-236 65240 13396 E2-256

Benadam-Lenrow

Ella

64047

E2-241

Chan ENT Chief Resident ENT Exam Room 1 ENT Exam Room 2 ENT Exam Room 3 ENT Exam Room 4 ENT Jr. Resident ENT Main line ENT Minor Room EYE/ENT Conference Room Makarewycz

Leslie

65535 64049 65193 65348 64622 66214 64048 60264 63322 65353

E2-246 E2-254 E2-244 E2-243 E2-242 E2-252 E2-253

Bohdan

64622 none

Nayak* Nielsen Sajjadi*

Jayakar Erik Hamed

61122 23098 E2-236 63202 63166 13199 E2-236

Sirjani* Sobejana

Davud Mehgan

67145 23350 E2-248 60596 3rd fl.

Sung* Tham

C. Kwang Maria

61122 23479 E2-236 kwangs@stanford.edu 66912 E2-246/B3- maria.tham@va.gov 130

Vo Yanokodani

Crystal Colleen

64046 66022

E2-241 3rd fl.

crystal.vo@va.gov

Yuan

Annie

65203 11671

E2-246

annie.yuan@va.gov

fbaik@stanford.edu ella.benadamlenrow@va.gov leslie.chan@va.gov

E2-250 E2-140 bohdan.makarewycz@ va.gov jnayak@stanford.edu erik.nielsen1@va.gov

hsajjadi@stanford.ed u or otology@hotmail.co m dsirjani@stanford.edu mehgan.sobejana@va.go v

colleen.yanokodani@va.g ov

Page 29 of 30 Rev: 5-31-21

OTHER SERVICES 3A

6508523396

or 64877

Audiology/Speech Path. (PAD) Bed Control

65597

Bldg 100 Room D2108

CDs CPRS Help hotline CT/MRI/Ultrasound/ Barium swallow Decedent Affairs Defenders Lodge ECHO Fisher House GT Removal Helpdesk (IT) - You

66969 65495 65050 65956 62777 6508583949 65432 61333 64621 61630 , 68800 64767

Ext. 63824

Anna Noble

or 69914

can also submit a ticket by using YOURIT icon on your desktop.

Interventional Radiology Navarre Transport

Nuclear Medicine Oncology (Lakedia Banks, RNP) OR (NAM) OSS RNP - Robin Boselli/Stephanie Kangas PFTs ROI SPD Telephone Care program VA travel

68800 8336282773 65520 65848 , 64948 61656 64154 /6204 9

(PET)

or 650-339-5117 62655

64207 67298 64212 8004550057 65686

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