ORSU-4053 - Acting Internship in Orthopedic Surgery, Applied Orthopedic Principles in Lower Extremity Surgery

ORSU-4053 - Acting Internship in Orthopedic Surgery, Applied Orthopedic Principles in Lower Extremity Surgery

Elective Title: Acting Internship in Orthopedic Surgery, Applied Orthopedic Principles in Lower Extremity Surgery
Course Number: ORSU-4053
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 1
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful completion of year 3 Surgery Clerkship. A C-form is required within a 30 day add/drop and must be signed by Bryanna Branch (blbranch@utmb.edu)
Responsible Faculty Director: Jie Chen, MD Periods Offered: 1-12 including holiday period 8 
Coordinator: Other Faculty:
Location to Report on First Day:
Contact Bryanna Branch(blbranch@utmb.edu) or 409-747-5701. 2.316 Rebecca Sealy

1. To learn the basic science and principles behind common orthopedic conditions afflicting the lower extremity. Will learn basics of fracture healing, implant science, mechanisms of injury, classification systems.
2. To gain comfort and experience in the operating room including basic knowledge of setup, positioning, assisting, and closing.
3. To participate in the care of patients seen on call including hip fractures, femur fractures, ankle fractures. While most of the pathology will be foot and ankle conditions, there will also be other lower extremity injuries who present from the emergency room.

1. Independently be able to perform a thorough history and physical examination of a foot and ankle patient in clinic and make a concise presentation.
2. Develop treatment plans for patients with a variety of lower and upper extremity conditions including hip fractures, femur fractures, tibia fractures, foot and ankle pathology
3. Position patients, close wounds, place hardware as indicated
4. Placing orders in the clinical setting including prescriptions, imaging orders, labs. Orders will need to be cosigned by resident or attending
5. Taking call with the orthopedic trauma service on one weekend, including seeing orthopedic consults, recognizing urgent ones such as open fractures or septic joints, and presenting them to transition care
6. Obtaining informed consent in clinic for surgical procedures

Description of course activities
1. On clinical days, student will observe a few patients, but will quickly function independently at the level of an intern including examining patients, developing treatment plans, presenting and writing notes. The student will have the ability to enter orders.
2. In the operating room, students will develop all the habits of a house officer including seeing the patient in the holding room, positioning the patient, assisting during the case, placing hardware as indicated, and closing/splinting.
3. Student will participate in rounding on inpatients as necessary.
4. Students will attend in weekly departmental conferences and prepare a 10-minute presentation to give during their rotation.
5. Students will take call on average one weekend per rotation with the orthopedic trauma team where they will see consults, identify which ones are urgent or emergent as appropriate, and handover information to the rest of the call team.
6. Students will obtain informed consent in clinic for surgical patients.

Type of students who would benefit from the course
All students interested in Orthopedics.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday Surgery Surgery
Tuesday Clinic Clinic
Wednesday Surgery Surgery
Thursday Clinic Clinic
Friday Clinic Clinic

 Average number of patients seen per week: 50
 Call Schedule: N/A

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Faculty and Resident's
  B. Frequency / Duration of Presentation(s)?
  C. Format - What guidelines are set for the student's presentation?
    Daily oral presentation
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    H&P's in the medical record on every patient seen by a student.
  B. Format - What guidelines are set for the student's written work?
    Student is expected to document chief complaint, history of present illness, past medical history, social and family history a review of systems and findings on examination.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    Related to the case
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Journal Club (attendance optional), attendance at fracture conference on Thursday morning, weekly Tuesday morning Foot and Ankle Surgery Teaching Rounds (during which the student will typically interact with faculty, residents and Research fellows) and weekly Wednesday morning Orthopedic Surgery Departmental Grand Rounds

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Clinical evaluation by upper-level residents and faculty with possible grade of Satisfactory/Unsatisfactory. Free, online orthopedic resources will be recommended.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    As above, all 4 EPAs will be addressed. Myself and my resident will observe and evaluate the student daily on their orders/prescriptions that they place in clinic. The orthopedic weekend call team will evaluate the student on transition care responsibility and their management of urgent/emergent consults. My resident and myself will teach the student how to obtain informed consent and evaluate him/her on the task. In addition, myself and residents will give direct feedback on a daily basis including goals to shoot for week to week

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    Students will perform physical exams on bones, tendons, ligaments, and neuromuscular structures. Students will perform tasks in OR such as closing, drilling and placing screws, positioning patients.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    Typically, the third-year student is becoming accustomed to the OR and will observe or be instructed what to do. The AI will be taught and will develop the following surgical skills above that of a MS3: positioning, draping, assisting, closing, and splinting. I expect the student to assist in the closure of all wounds from day 1. The student will be able to do so independently by the end of the rotation. In addition, there will be emphasis on having an understanding of orthopedic basic science principles. Finally, the student will be given the ability to place orders in the clinic and consent patients trauma team.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    Students will study anatomy for cases and synthesize history and exams for a differential diagnosis. They will also be able to write notes. Students will be able to place orders, and these will be cosigned or checked by myself or the resident. Case reports and research projects will be made available to interested students.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    Students will learn surgical anatomy, exam skills, and orthopedic diseases. In addition, will develop habits in the clinic and the OR which will help them in intern year. My week has around 18 hours of built-in clinic time each week, and I spend about 20 hours operating. In addition, the student will be expected to take call on one weekend with the orthopedic trauma team.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    1 week into the rotation, students will schedule a midpoint evaluation session with Faculty. Faculty will remediate as needed.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Dr. Chen will meet with each student at midpoint and review the Acting Internship Criterion Based Evaluation Form. Together, the student and Dr. Chen will identify where the student is performing in each area of the evaluation and discuss ways to improve and grow.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    I will be the primary faculty. However, the student is encouraged to work with Dr. Panchbhavi and/or Dr. Foreman when I have time off. The student will work the most directly with myself and my resident. We will both directly supervise the student and will both provide direct verbal feedback on a daily or weekly basis