GOALS AND OBJECTIVES

 

The ultimate goal of the training program at the University of Oklahoma College of Medicine for Cardiothoracic Surgery is to graduate a cardiovascular and cardiothoracic surgeon accomplished in technical skills and with a base of knowledge explicitly credible for the care of patients for cardiothoracic disease. The accomplishment of this task should interface with the contemporary medical care environment and within the laws and social mores of our society. The objectives for obtaining this goal are encountered throughout the training program with particular application to specific service rotation opportunities.


The program includes an ongoing and maturing experience with patient care from initial referral to chronic care disposition as it interrelates with the entire healthcare system within the medical center. Within the educational framework, attention to the six general competencies will be at the forefront of objectives and assessment of resident performance. Those competencies are emphasized as patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. The attainment of competence in these six areas will be assessed continually and periodically throughout the residency program with personal observation and specific critique of portfolio accruement and 360-degree analysis by response to questionnaire by faculty and paramedical support personnel.

The residency is structured in rotation blocks designed in a graduated pattern to meet the goal of developing the accomplished cardiothoracic surgeon.

The rotation blocks:

Training Year 1
  Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
VAMC                        
Presbyterian                        
Women's and Newborn                        
Training Year 2
  Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
VAMC                        
Presbyterian                        
Women's and Newborn                        

The blocks of rotations are for successive years in the two-year residency experience.

ROTATIONS

Rotation 1 - Veterans Administration Medical Center - July 1 through October 31. The rotation is devoted to the Veterans Administration Medical Center experience and the respective healthcare system. This rotation will involve the structure of clinical experience as described for rotation 1. The electronic chart system established at the Veterans Administration Medical Center will be a particular exposure for a system-based practice. The clinical experience in attending staff support will be as described for the initial rotation at the Presbyterian Tower. Cardiac surgical activity will have a particular emphasis to off-pump coronary revascularization.

More explicit descriptions of exposure and expectations for those clinical areas are as follows:

Cardiac

  • Formulation of clinical presentation by review of pertinent history and physical parameters.

  • Interpretation of diagnostic studies to include those of cardiac catheterization with angiography and pressure flow assessment.

  • Interpretation of echocardiographic data.

  • Interpretation of myocardial resonance angiographic data along with that of computed tomography (CT) scanning.

  • Disposing of particular patient care by evidence-based information for risk benefit analysis.

  • Operative experience will be garnered and advanced by accomplishment and will begin with surgical exposure by sternotomy or thoracotomy, instrumentation for cardiopulmonary bypass with myocardial preservation techniques of antegrade and retrograde perfusion with associated monitoring.

  • A representative listing of expected procedures includes the following:
    - Harvesting of internal cardiothoracic pedicle for conduit.
    - Harvesting of saphenous vein for conduit.
    - Harvesting of radial artery for conduit.
    - Revascularization of the myocardium with conduit attachment to the coronary arteries in the arrested non-beating heart, progressing to beating heart and off-pump techniques.
    - Valve replacement and repair in those situations of relatively less challenge and complexity.
    - An initiation of experience to the more basic aortic root replacement.
    - Intraoperative instrumentation for permanent pacemaker support.
    - Repair of cardiac chamber defects beginning with the more simplistic presentation.
    - Instrumentation for hemodynamic support by intraaortic balloon, extracorporeal circulation, or ventricular assist.
    - Surgery for chronic disease or trauma of the great vessels with reconstruction and physiologic circulatory support.

  • Along with technical activities comes the accruement of the following:
    - An appreciation of cardiopulmonary support and related physiology.
    - An appreciation of drug and anesthetic interface with various pathophysiological situations.
    - An appreciation of ventilatory support, both acutely and chronically for the cardiac patient.

Pulmonary Disease

  • Applying the assimilated history and physical data for appropriate initiation of study and disposition for surgical or non-operative care.

  • Evolving an understanding of preoperative and diagnostic assessment by radiographic analysis including x-ray, CT scanning, magnetic resonance studies, positive emission tomography (PET), pulmonary function studies and blood gas analysis.

  • Realizing appropriate related concerns of infectious disease.

  • Gaining a particular awareness of limits of physiological reserve with the sacrifice of lung tissue.

  • Application of ventilatory support in the perioperative setting.

  • Awareness of effects of infectious disease for applied surgical and medical support.

  • Operative experience will advance by accruement of expertise and will include the following:
    - Bronchoscopy, rigid and fiberoptic
    - Mediastinoscopy
    - Thoracoscopy
    - Thoracotomy
    - Incisional and excisional biopsy
    - Wedge excision of pulmonary parenchymal lesion
    - Segmentectomy
    - Lobectomy
    - Pneumonectomy
    - Debridement of the pleural space and decortication of entrapped lung
    - Drainage of the pleural space
    - Biopsy, resection, and reconstruction of the chest wall
    - Thoracoplasty
    - Tracheal and bronchial resection and reconstruction for benign, malignant and traumatic disease

Esophageal Disease

  • Assimilation of history-physical data for appropriate analytical testing for disposition to operative and non-operative therapy.

  • Assessment of disease concerns by radiography to include x-ray, contrast swallow analysis, CT and magnetic resonance analysis, positive emission tomography, esophageal ultrasound, esophageal motility analysis and acid reflux study analysis.

  • Operative experience will include the following:
    - Esophagoscopy, rigid and fiberoptic
    - Esophageal biopsy
    - Esophageal dilatation
    - Anti-reflux procedures, transthoracic
    - Esophageal resection and reconstruction of the alimentary tract and maintenance of nutritional support

Congenital Heart Disease

The entire residency experience will involve an exposure to the pathophysiology and methods of support of congenital cardiac disease. In addition to an ongoing awareness through conference discussion, a more explicit participation will be gained in the second year-middle block rotation. At that time the resident will share in the operative activity with an emphasis to the following:
- Vascular access
- Systemic to pulmonary shunting
- Septal defect repair
- Aortic coarctation repair
- Pacemaker implantation
- Valvular and outflow tract reconstruction as appropriate for complexity

The involvement in the care of infants and children with congenital cardiac anomalies is more basic than complete with any further devotion relegated to a "post-graduate" experience.

The examples by listing represent many but not necessarily all of the clinical concerns and technical applications for the surgeon in training. All experiences will be with the direct involvement of a respective staff attending from initial referral to disposition of care. The surgical experience for technical application will be with particular attending interface with advancement of resident autonomy as expertise evolves.

Rotation 2 - Presbyterian Tower, OU Medical Center - November 1 through February 28/29.

The rotation begins with an introduction to the OU Medical Center healthcare system at Presbyterian Tower, OU Medical Center with an interface with the institution and its delivery of healthcare. During this rotation there will be an exchange of call responsibility at the Veterans Administration Hospital as well as Women's and Newborn. The primary activity, however, will be at the Presbyterian Tower location. An ongoing activity with the structured system of healthcare involves the outpatient clinic, emergency room, radiology services, pathology services, operating room and intensive care, as well as facilities for rehabilitation and discharge. Attention to care map protocol will be paramount in this experience of learning and delivery of care. The experience will involve exposure to cardiac, pulmonary, mediastinal, and esophageal disease entities as well as those involving the thorax in general including trauma as well as diseases of the chest wall and included structures. The assimilation of collected data will be reviewed with attending counsel followed by appropriate operative intervention or non-operative supportive care. This process will continue through the postoperative period of care in both the intensive care unit and the rehabilitation areas. The experience will include exposure to and adaptation of diagnostic modalities in all areas of cardiothoracic disease. The attention to specific patient care concern and disease entities is initiated by patient referral and not by separated assignment, thereby representing a clinical practice experience.


Rotation 3 - Veterans Administration Medical Center - March 1 through June 30.  A return to VAMC for completion of the third block of the first year of surgical residency will again be with similar structure but with a maturing experience and an advancement of autonomy for resident participation in clinical activities in surgical procedures.

Rotation 4 - Presbyterian Tower, OU Medical Center - July 1 through October 31. The clinical experience of rotation 4 will involve, in addition to the previously described clinical and surgical experience, emphasis toward efficiency in off-pump and beating heart coronary revascularization as well as valve repair and stentless valve replacement.


Rotation 5 - Veterans Administration Medical Center - November 1 through February 28/29.  A return to VAMC for a fifth block, but during the second year of surgical residency will again be with similar structure but with a maturing experience and an advancement of autonomy for resident participation in clinical activities in surgical procedures.

Rotation 6 - Presbyterian Tower and Women's and Newborn Tower, OU Medical Center - March 1 through June 30. Residency will be completed with the final rotation at the split between Presbyterian Tower and Women's and Newborn Tower on the pediatric cardiac surgery service.  This will provide a somewhat more controlled pace and clinical structure will allow the resident to prepare for "graduation" with pursuit of particular surgical activities with regard to needed emphasis and exposure to the pediatric cardiac service.



The attainment of medical knowledge will be enhanced throughout the residency with exposure to conference and journal club activities. Practice-based learning and improvement will be emphasized throughout with appropriate literature review and discussion in the formal conference setting. Scholarly activities will involve attendance at selected national meetings and didactic review courses. The in-training service examination serves as a particular objective for surveillance of medical knowledge. System-based practice will be emphasized throughout the residency with development and adherence to particular care map protocol and quality assessment in each respective institution.

The program director and program coordinator for the residency training program will be with direct personal attention and involvement for assuring adherence to the curriculum.