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INTRODUCTION

The following objectives have been delineated and should apply to the cardiac surgery residents entering their final year of training as Chief Resident on the Adult Cardiac Surgery Services of both the Royal Victoria Hospital and Montreal General Hospital sites.Ìý These objectives are to be enunciated according to the Royal College CanMEDS Project.Ìý The residents are expected to review all this material at the start of their rotations and re-evaluate these objectives at the end of the rotation.Ìý The attending staff surgeons are also expected to be well aware of these objectives and discuss the progression of the resident during the 6-month rotation spent on the service.

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AIMS OF THE NEW PROGRAM:

1. Chief residents in Cardiac Surgery will clearly understand what knowledge, skills and abilities will be expected throughout their 6-month rotation.
2. The chief resident should be able to assess, investigate, diagnose, manage clinically and surgically adult patients presenting with all the common cardiac surgical pathologies encountered in a tertiary and quaternary care hospital.
3. At the completion of his/her rotation, the chief resident will be expected to be able to function at a consultant level and be capable of managing patients undergoing cardiac surgical procedures, the pathophysiology behind their disease process as well as all the complications and their management.

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MEDICAL EXPERT:

The Cardiac Surgery CTU has subdivided this area into 4 areas:Ìý 1) Basic Science, 2) General Clinical Knowledge, 3) Cardiac Surgical Knowledge, and 4) Technical Skills.

1.ÌýÌý Basic Science:

• The chief resident in Cardiac Surgery will fully understand all of the cardiac and vascular physiology as it applies to the disease process of his/her patients will have during the rotation.
• The chief resident should fully understand the pathophysiology of atherosclerosis as it applies to the cardiac, vascular and cerebral systems.Ìý
• The chief resident will have thorough knowledge of the pathophysiological mechanism of simple and complex atrial and ventricular arrhythmias.
• The chief resident will have excellent knowledge of basic fluid and electrolyte and acid base balances, pathophysiology of extra-corporeal circulation.
• A full understanding of hemodynamic parameters as they apply to normal and abnormal cardiac and vascular pathologies.
• Thorough knowledge of cerebral metabolism under normal and hypothermic conditions.
• Thorough knowledge of infectious processes as they apply to surgical wounds and cardiac valves.
• Thorough knowledge of basic hemodynamic parameters as they apply to normal cardiac pathology as well as to ventricular assist devices.
• Thorough knowledge of basic principles of immunosuppression.

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2.ÌýÌý Cardiac Surgical Knowledge:

• The chief resident will recognize the unique natural histories of adult cardiac surgical diseases.
• The chief resident will understand and take an active part in the diagnosis, investigation and establishment of surgical indications for the following disease processes:
• Coronary artery disease – stable, unstable.
• Myocardial infarction and its mechanical complications, namely left ventricular rupture, acute mitral regurgitation, ventricular septal defect, shock.
• Aortic valve disease [insufficiency – stenosis – nicks in the acute, chronic or endocarditis setting].
• Pericardial disease as it applies to constrictive pericarditis, pericardial tamponade or malignant effusions
• Mitral valve disease [regurgitation – stenosis – combined acute, chronic and endocarditis].
• Tricuspid valve disease [tricuspid regurgitation and stenosis either isolated or combined with left sided valvular lesions].
• Ascending aortic disease and arch disease, namely aneurysmal dilatation, acute and chronic dissection, and extensive calcification.
• Extra-cranial vascular disease as it applies to Cardiac Surgery.
• Adult congenital disease.
• Arrhythmia [pre-, peri- and post-operative, namely pacemaker, epicardial and endovenous].
• Surgical ablative procedures.
• Percutaneous ablative procedures.
• Automated implantable defibrillators.
• Benign and malignant cardiac tumors [diagnosis, investigations and principles of treatment (surgical and non-surgical)].
• Clear understanding of how to interpret hemodynamic tracings, coronary angiography, aortic angiography, cardiac Magnetic Resonance Imaging as well as echocardiography.
• The chief resident will be expected to be working under the direction supervision of the attending staff, but will be functioning at a near consultant level with the highest level of responsibilities in the peri-operative management issues of all of the patients on the Cardiac Surgery Service.Ìý
• The chief resident will be involved with all of the elective and urgent consultations originating from the Emergency Room, the Coronary Care Unit or the Intensive Care Unit.

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3.ÌýÌý Technical Skills:Ìý

• At the end of the surgical rotation, the chief resident will be able to perform in an independent or semi-independent fashion the following tasks:
• Cannulation for extra-corporeal circulation either anatomic or extra-anatomical.
• Harvesting of arterial [internal thoracic and gastro-epiploic arteries] and venous conduits [greater and lesser saphenous veins].
• Appropriate setting up of all of the operating field, cannulas and equipment for safe conduct of the operation.
• Distal and proximal vein and arterial coronary anastomoses.
• Establishment of a hemostatic shield at the completion of the procedure.
• Full understanding of the prerequisites to safely wean a patient off extra-corporeal circulation.
• Interpretation ofÌý peri-operative transesophageal echocardiography.
• Replacement of the ascending or the arch of the aorta either with a tube graft or a composite valve conduit with re-implantation of the coronary buttons.
• Replacement of the aortic valve either with a bioprosthesis or mechanical prosthesis.
• Good understanding of the application of stentless bioprostheses in the aortic position as well as valve sparing aortic root reconstructions.
• Tricuspid valve replacement or repair with an annuloplasty ring.
• Capable of mitral valve repair as it applies to implantation of an annuloplasty ring.
• Good understanding of the principles of more complex mitral valve repairs, such as posterior quadrangular resection, chordal transfer, artificial chordae, etc.
• Resection of left ventricular aneurysm either with linear exclusion or endocardial approach.
• Preparation of the surgical field for beating heart surgery.
• Assistance in the performance of distal anastomoses on a beating heart.
• Independent implantation of epicardial, atrial and ventricular pacemakers as well as independent implantation of dual and single chamber endovenous pacemakers.
• Implantation of endovenous defibrillators.
• Transthoracic implantation of epicardial pacing electrodes.
• Re-exploration for tamponade in post-operative cardiac surgery patients.
• Performance of pericardial windows using either the subxiphoid or the thoracic approach.
• Insertion and excision of intra-aortic balloon pump.
• First assistance in the implantation of mechanical assist devices.
• Cardiac transplantation.

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COMMUNICATOR:

• The chief resident will obtain cardiac histories from patients and their relatives under elective and emergency conditions.
• The chief resident will be able to supervise the junior residents in their taking of case histories and physical examinations, and confirm that they were exact and also proceed with education of the more junior house staff.
• The chief resident will have total knowledge of all the patients on the Cardiac Surgery Ward as well as the Intensive Care Unit, and will provide written communication in the medical charts as to the progression and treatment plans of these patients.Ìý
• The chief resident will convey pertinent patient data to the attending staff in an appropriate and pertinent timeframe.
• The chief resident will communicate timely information to patients and their families.

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COLLABORATOR:

• The chief resident will function at a near consultant level and be a direct link between the more junior house staff, the nursing staff and the attending staff.
• The chief resident will perform consultations in the Intensive Care Unit, the Emergency Room and the Coronary Care Unit, and will be assessing ward patients and be the first assist in the operating room.
• The chief resident will also be responsible to respond in a timely fashion to emergency calls from either the Emergency Room or the Cardiac Catheterization Lab.

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MANAGER:

• The chief resident will be responsible for the good conduct of the day-to-day activities on the ward and the distribution of the workload to junior residents and medical students.
• The chief resident will ensure that proper discharge summaries and chart keeping is performed according to Canadian standards.
• The chief resident will be directly involved with one-to-one teaching with the more junior house staff.
• The chief resident will be indirectly involved with the bed management in the Intensive Care Unit and the Surgical Ward.
• The chief resident will comprehend the criteria for discharge of patients either from the ICU or from the ward and a clear indication for transfer of these patients to referring hospitals or rehabilitation centers.
• The chief resident will be responsible to keep track of all of the complications and mortalities on the ward, and be ready to present these at Mortality and Morbidity Rounds in a timely fashion.
• The chief resident will understand principles of cost effective care, limited resources and evidence-based medicine, and be able to educate the more junior house staff and the nursing staff on these issues.

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HEALTH ADVOCATE:

• The chief resident will provide prognostic information to the patients and their families.
• The chief resident will be aware of cardiac surgical alterations in anatomy or physiology that may impact on the patient’s future health.
• The chief resident should be in a position to provide appropriate advice and information to the patients in the management of their cardiovascular risk factors.
• The chief resident should also be able to guide these patients through post-operative or post-myocardial infarction rehabilitation programs.
• The chief resident should be expected to provide realistic information as to what the patient can expect when he or she returns home.

SCHOLAR:

• The chief resident will demonstrate knowledge of embryology, anatomy, physiology and pathology related to cardiac surgical topics in a methodical or where possible an evidence-based manner.
• The chief resident will be responsible to give ad hoc topic reviews at Divisional Rounds as well as at Surgical Grand Rounds.
• The chief resident will be expected to fully understand the causes of complications and mortalities as he or she presents them at Mortality and Morbidity Rounds.Ìý Research reviews should also be provided at the time of these presentations in order to educate the rest of the audience.
• The chief resident will be involved in a small clinical or basic science research project during his or her adult rotation and be responsible to present his or her work at national, international or provincial meetings.
• The chief resident will be able to proceed with the establishment of a study schedule in preparation for the final Royal College exams.

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PROFESSIONAL:

• The chief resident will demonstrate sensitivity to gender, culture, and ethnic differences.
• The chief resident will participate in organized multidisciplinary meetings on patients and appreciate the role in the overall cardiovascular setting.
• The chief resident will attend national and international conferences regarding cardiac surgical issues as well as ethics issues, outcome evaluation, peer review, and maintenance of certification occurring during that rotation.
• The chief resident will be available in a timely fashion to respond to emergency or urgent calls from the Intensive Care Unit or the Surgical Ward.
• The chief resident will perform his duties with a positive attitude.
• The chief resident will attend all of the teaching rounds in the operating rooms as expected or outlined above.
• The chief resident will perform all of the educational activities and evaluations as requested, including a complete operative log.