PGY-1

Rotations during this year include neurosurgery, internal medicine, anesthesia, emergency medicine, neuroradiology and neuropathology. The PGY-1 will provide a foundation for the fundamentals of neurosurgery and strong insight into managing patients with neurologic disease.

Throughout this year, the PGY-1 resident will attend weekly neurosurgery conference, didactics and grand rounds. They will also participate in monthly journal clubs and participate in research. PGY-1 residents will participate in grand rounds, present cases, research journal articles, and discuss cases with Attendings and senior resident staff. Direct oversight is provided by senior residents and attending staff regarding conferences and educational meetings.

Neurosurgery PGY-1 (3 months)

PGY-1 residents will be on the neurosurgery service at Cooper University Hospital learning how to manage patients in neuro-oncology, neuro-critical care, vascular neurosurgery, neuro-trauma, spinal degenerative disease, functional neurosurgery, peripheral nerve pathology, and pediatric neurosurgery. Expectations at the completion of this 3-month rotation for the PGY-1 resident are:

Patient Care:

• Perform and document a detailed history and physical examination with direct supervision of senior residents and attending physicians. There is emphasis on learning a thorough neurological examination.
• Evaluate polytrauma patients, assess appropriate severity score and provide initial treatment.
• Develop insightful differential diagnosis.
• Provide routine perioperative care for patients.
• Recognize and begin work-up for a deteriorating neurological patient.
• Recognize, initiate work-up and initiate treatment of a seizure.
• With direct oversight, learn the technique for placing intracranial pressure monitors and advanced cerebral monitor devices.
• Develop an understanding of CSF shunt function and steps to evaluating their function and programming.
• Describe intracranial and extracranial vascular anatomy.
• Describe and identify clinical signs of ischemic and hemorrhagic stroke.
• Develop skills to assist basic neurosurgical procedures in the neurosurgical operative suite.
• Identify medical errors and sentinel events and lead an evidence-based discussion following the event.
• Learn how to apply medical knowledge to patient care.

Medical Knowledge:

• Localize lesions based on the neurological exam.
• Generate acute medical treatment plans for symptomatic neoplastic mass lesions.
• Understand the physiology of intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) physiology.
• Describe cerebral autoregulation.
• Know guidelines and indications for ICP monitoring and surgical traumatic brain injuries.
• Understand how ventilator and respiratory physiology effect ICP and CNS physiology.
• Understand the physiology of anticoagulation and hemostasis including the mechanism of action of common anticoagulant and antiplatelet medications.
• Describe principles of nutritional support for neurosurgical patients.
• Understand the anatomy of the basal ganglia, thalamus, and cortex and correlated with surgical targets for functional neurosurgery.
• Describes the physical findings and differential diagnosis of common movement disorders.
• Describes the pathophysiology of common seizure disorders and medical therapy for status epilepticus.
• Describe the anatomy of the spinal cord and thalamic, brachial and lumbar plexuses and major nerves of the extremities.
• Identify anatomical regions associated with pain and pain modulation.
• Describe major nerve injury classifications and the prognosis and time course for recovery of each.
• Identify how aberrations in developmental neuroanatomy results in common CNS congenital anomalies and vascular lesions.
• Describes normal CSF physiology and pathological mechanisms causing hydrocephalus.
• Understand how the developing brain responds to injuries.
• Understand proper utilization and dosing of narcotics in pediatric patients.
• Understand how to localize radicular patterns of pathology to spinal cord levels.
• Understand physical findings and differential diagnosis of degenerative spinal disorders (e.g., radiculopathy, neurogenic claudication, spondylotic myelopathy).
• Describe basic principles of spine biomechanics, spinal cord anatomy and diagnosis of cauda equina.
• Know dermatomal and myotomal patterns of spinal cord injury.
• Describe the pathophysiology of spine and spinal cord injuries.
• Understand basics of differentiating stable and unstable spinal pathologies.
• Describe intracranial and extracranial vascular anatomy, including vascular territories.
• Understand the physiology and mechanisms of cerebral autoregulation.
• Describe the role of intracranial and extracranial atherosclerosis in neurosurgical patients.

Internal Medicine PGY-1 (2 months)

Patient Care:

• Acquire accurate and relevant history from the patient in an efficiently customized, prioritized, and evidence-based driven fashion.
• Seek and obtain appropriate, verified, and prioritized data from secondary sources (e.g., family, records, pharmacy).
• Perform an accurate and focused physical examination targeted to the patient's complaints and medical conditions; identify pertinent abnormalities using common physical tests.
• Accurately track relevant changes in patients' physical exams.
• Identify patient's central clinical problem by interrogating all available data, including history, physical examination, and preliminary laboratory data.
• Develop prioritized differential diagnoses, evidence-based diagnostic and therapeutic plan for common inpatient and ambulatory conditions.
• Formulate a comprehensive problem list for each patient.
• Use common diagnostic tests, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, electrocardiograms, chest radiographs, pulmonary function tests, and urinalysis to make evidence-based clinical decisions.
• Recognize life threatening conditions in need of emergent care.
• Recognize when to seek additional guidance.
• Manage inpatients with supervision.

Medical Knowledge:

• Understand relevant pathophysiology and basic science for common medical conditions.
• Describe the pathophysiology of myocardial infraction (MI) and congestive heart failure (CHF).
• Demonstrate sufficient knowledge to diagnose and treat common conditions that require hospitalization.
• Understand indications for common diagnostic testing, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids and how to interpret these data.

Anesthesia PGY-1 (1 month)

Patient Care:

• Demonstrate knowledge of operating room safety.
• Demonstrate proper techniques of airway management, including mask ventilation, placement of laryngeal mask airway and orotracheal intubation.
• Demonstrate the ability to recognize inadvertent endobronchial intubation.
• Develop beginning skills for the establishment of peripheral intravenous access.
• Perform an efficient and thorough, focused pre-operative assessment, including the need for appropriate laboratory and diagnostic testing.
• Identify potentially challenging airways and develop a plan for their management.
• Demonstrate an understanding of the principles of post-anesthesia care, including recognition and management of common post-operative issues, including pain, nausea and vomiting, emergence delirium and post-operative ventilation.

Medical Knowledge:

• Demonstrate an understanding of the role of physiology and pharmacology, including drug disposition and metabolism, in the anesthetic management of the patient.
• Demonstrate a basic understanding of the techniques of general and regional anesthesia and conscious sedation, as well as the risks and benefits of each.
• Demonstrate basic skills in the interpretation of intra-operative monitoring, including capnography, oxygen saturation, arterial blood gas analysis and hemodynamic measures.
• Demonstrate the ability to estimate fluid requirements and provide a rationale for volume replacement therapy.

Neuroradiology PGY-1 (1 month)

Patient Care:

• Learn to obtain informed consent, by explaining the risks and benefits of contrast enhanced CT/MR to the patient.
• Correlate radiographic tumor location with ventricular, cranial nerve and vascular anatomy.
• Learn appropriate techniques for injection of contrast (including the use of power injectors).
• Learn to recognize and treat contrast reactions.
• Observe the performance of diagnostic angiograms of the cervical and cranial vessels.
• Learn to perform fluoroscopically guided punctures of the lumbar spinal canal for the purpose of myelography, spinal fluid collection, and intrathecal injection of medications.

Medical Knowledge:

• Become familiar with the appearance or major intracranial structures as visualized on axial CT and MR scans.
• Demonstrate the ability to identify all major structures and components of the brain, ventricles and subarachnoid (cisterns) space.
• Learn the anatomy of the calvarium, skull base and soft tissues of the neck as displayed on plain radiographs.
• Become familiar with the normal appearance of the spine on plain radiographs and axial CT scans.
• Identify the assessment of spinal alignment and demonstrate the ability to recognize all osseous components of the spinal canal.
• Learn to identify the large vessels of the cervical and intracranial regions (Carotid, Vertebral and Basilar arteries, Jugular veins and dural venous sinuses) as they appear on routine CT and MR studies of the head and neck.
• Become familiar with the common traumatic, ischemic and inflammatory conditions of the brain, skull base, neck and spine.
• Become familiar with imaging parameters including window and level settings, slice thickness, interslice gap, and helical imaging parameters, and image reconstruction algorithms (e.g., soft tissue and bone).
• Learn the typical CT density of commonly occurring processes such as edema, air, calcium, blood and fat.
• Learn the basic physical principles of MR. Be able to identify commonly used pulse sequences and become familiar with standard MR protocols. Learn the intensity of normal tissues on routine pulse sequences.
• Develop skills in the interpretation plain films of the skull. Learn to interpret CT scans with a particular emphasis on studies performed on individuals presenting with acute or emergent clinical abnormalities (infarction, spontaneous intracranial hemorrhage, aneurysmal subarachnoid hemorrhage, Traumatic Brain Injury, infection, hydrocephalus, and brain herniation).
• Learn to identify common acute emergent lesions. Become familiar with the plain film and CT appearance of (a) traumatic (fractures and soft tissue injuries) of the orbit, skull base, face and petrous bones and (b) inflammatory (sinusitis, orbital cellulitis, otitis, mastoiditis, cervical adenitis and abscess) lesions. Learn to identify airway compromise and obstruction.
• Learn the appearance of traumatic lesions on plain radiographs with an emphasis on findings of spinal instability. Become familiar with the CT and MRI findings of degenerative disease.
• Learn to recognize the angiographic features of extra- and intracranial atherosclerosis utilizing catheter angiography MRA, and sonography.
• Learn to recognize the normal appearance of the brain (e.g., myelination), spine (e.g., ossification), and Head & Neck (e.g., sinus development) encountered in the newborn, infant, and child.
• Demonstrate the ability to identify the features of hydrocephalus on CT and MR.

Neuropathology PGY-1 (1 month)

Patient Care:

• Develop an understanding of how to diagnose common neoplastic, degenerative, reactive, and metabolic conditions involving the brain and spinal cord, their coverings, skeletal muscle, and peripheral nerve by examining frozen and permanent sections of lesions of the nervous system.
• Learn appropriate methods of intraoperative diagnosis, grossing techniques, special stains and immunohistochemistry that are applicable to neuropathology.
• Learn how to correlate clinical, radiological, laboratory and electrodiagnostic features important to the accurate diagnosis of neuropathological conditions with neuropathological findings.

Medical Knowledge:

• Become familiar with the pathogenesis and typical morphology of diseases of the central nervous system, muscle and peripheral nerve.
• Understand the natural history, effects of treatment, and prognosis of common neurological diseases.
• Understand the role of the nerve and muscle biopsy in the evaluation of neuromuscular disease.
• Develop differential diagnoses for common lesions based upon clinical and laboratory information along with the gross and microscopic findings in each case.

Emergency Medicine PGY-1 (1 month)

Patient Care:

• Gather accurate and complete information about patients from the patient, the patient’s family, friends and health care providers, and the patient’s medical record.
• Demonstrate the ability to effectively perform an emergency department history and physical exam that is thorough for the patient's chief complaint.
• Make an appropriate differential diagnosis.
• Develop a treatment plan and implement it.
• Reassess and follow through on the patient’s work up. Educate and counsel patients on their treatment plan and their final diagnoses.
• Demonstrate competence in basic emergency procedures.
• Demonstrate the ability to present clinical findings and management plans in a cohesive and organized manner to the attending.

Medical Knowledge:

• Demonstrate an understanding of the etiologies, prevalence, diagnosis and treatment of emergency conditions presenting to the emergency department.
• Demonstrate an understanding of emergency department basic procedures; preparation, treatment and after care.
• Demonstrate an understanding of the indications for and limitations of laboratory and radiological testing.
• Demonstrate an investigatory and analytical approach to thinking through clinical situations.
• Residents will present and discuss clinical findings and management plans with the attending.
• When indicated, residents will seek out supplementary sources of information such as literature review and discuss their findings with the attending.

General Surgery/ Acute Care Surgery PGY-1 (2 months)

Patient Care:

• Learn to efficiently gather all relevant information for acute patients.
• Will perform a detailed general surgical exam and order relevant tests.
• Will appropriately triage surgery patients.
• Interact with consultants to optimize patient care.
• Lead conversations with patients and families regarding goals of care.
• Manage airway and perform endotracheal intubation.
• Insert arterial and central venous catheters.
• Can assist in performing a cardiac echo and abdominal ultrasound.
• Can assist with laparoscopy.
• Coordinating acute trauma care (running a trauma code).

Medical Knowledge:

• Will know criteria for need of: immediate airway management, immediate chest tube insertion, immediate treatment of tension pneumothorax.
• Know when emergency department thoracotomy is warranted.
• Identify need for acute surgical intervention.
• Identify need for immediate intervention for spinal cord injury.
• Understand process for clearing a cervical spine from injury.
• Know how to differentiate levels of care i.e. Level I, II, III, IV.
• Understand interdisciplinary care: scene to discharge.
• Understand role of rehabilitation in trauma patients.
• Understand the epidemiology of trauma and its economical impact on health care.

Critical Care PGY-1 (1 month)

Patient Care:

• Can perform detailed history and physical exam for critical care patients.
• Will know how to incorporate medical co-morbidities into develop patient-specific treatment plans.
• Will order appropriate diagnostic tests and be involved in their interpretation.
• Will apply data from relevant literature in the treatment of critical care patients.
• Can explain risks and benefits of ventilator support.
• Can manage an airway and can perform endotracheal intubation.
• Can insert arterial and central venous catheters.
• Explain risks and benefits of ventilatory support.
• Interpret diagnostic studies (e.g., chest x-ray [CXR], brain computed tomography [CT], echocardiogram).
• Manage intra-cranial hypertension (e.g., hyperosmolar agents, cerebral spinal fluid [CSF] drainage).
• Diagnose and manage spinal or hypovolemic shock.

Medical Knowledge:

• Describe modes of mechanical ventilation and management of pulmonary shunting and dead space
• Understand role of prophylaxis for deep vein thrombosis (DVT).
• Know indications for intravenous thrombolytic therapy in ischemic stroke.
• Describe the clinical and imaging characteristics of delayed cerebral ischemia after subarachnoid hemorrhage.
• Can describe the pathophysiology and medical management of intra-cranial hypertension and cerebral edema.
• Describe modes of mechanical ventilation and management of pulmonary shunting and dead space.
• Understand etiology and relevant imaging of traumatic intra-cranial hemorrhage and parenchymal injuries.

Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism and System-based Practice (Accrued throughout PGY-1)

Practice Based Learning and Improvement:

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Each provided through role modeling by attending, participation in workshops, and direct patient care experience. Assessed through evaluation form by attending, and self-assessment.

• Demonstrate the ability to recognize resources, providers, and systems necessary to provide high-quality neurosurgical care.
• Demonstrate the ability to appreciate the patients’ interest and convenience in care management plans.
• Demonstrate an understanding and be able to appropriately discharge patients in a timely fashion.
• Demonstrate a willingness to collaborate with administrative leaders from various departments to improve the quality of health care delivery.
• Demonstrate the ability to obtain and utilize available resources to optimize neurosurgical care.
• Demonstrate ability to track operative cases and appropriately document in the case log.

Interpersonal and Communication Skills:

Residents must be able to demonstrate interpersonal and communication skills that assist in effective information exchange and be able to team with patients, patients’ families, and professional associates. Each provided through role modeling of Attending, participation in workshops or didactic conferences, and direct patient care experience. Assessed through evaluation form by attending, evaluation form by team members or peers and self-assessment and evaluation form.

• Demonstrate the ability to effectively communicate with patients and their families.
• Demonstrate the ability to counsel patients and families on the risks, benefits, and alternatives to surgery.
• Demonstrate the ability to communicate all adverse events in a timely fashion to patients, senior residents, and attending physicians.
• Demonstrate the ability to respond to requests of staff in a prompt and professional manner.
• Demonstrate the ability to work effectively with ancillary care and other medical professionals (e.g., pharmacist, social worker, occupational and physical therapist).
• Demonstrate the ability to provide effective and professional consultations to other physicians and health care professionals.
• Demonstrate the ability to effectively communicate with other members of the neurosurgery team
• Demonstrate the ability to complete and maintain all reports, history and physicals, consults, progress notes, and discharge summaries in a timely manner as set forth by hospital guidelines.

Professionalism:

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse population. Each provided through role modeling by attending, participation in workshops, and direct patient care experience. Assessed through evaluation form by attending, and self-assessment.

• Demonstrate dependability, honesty, responsibility and punctuality in day to day activities.
• Demonstrate respectful behavior when interacting with residents, attending physicians, and other health care professionals.
• Explain the process of informed healthcare decision making, including the elements that must exist and specific components of an informed consent discussion.
• Demonstrate sensitivity and responsiveness to cultural differences, sexual preferences, ages, beliefs, socioeconomic status, behaviors, and disabilities of patients and professional colleagues.
• Partake in the end of life decision-making and maintenance of proper rapport with patients and families.
• Demonstrate the ability to recognize patient care issues and respond in a timely manner.

System-based Practice:

Residents must demonstrated an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Each provided through role modeling by attending, participation in workshops, and direct patient care experience. Assessed through evaluation form by attending, and self-assessment.

• Demonstrate the ability to recognize resources, providers, and systems necessary to provide high-quality neurosurgical care.
• Demonstrate the ability to appreciate the patients’ interest and convenience in care management plans.
• Demonstrate an understanding and be able to appropriately discharge patients in a timely fashion.
• Demonstrate a willingness to collaborate with administrative leaders from various departments to improve the quality of health care delivery.
• Demonstrate the ability to obtain and utilize available resources to optimize neurosurgical care.
• Demonstrate ability to track operative cases and appropriately document in the case log.