Curriculum, Caseloads, Facilities
Clinical Curriculum 2008 - 2009
A) By Year
First Year
The first year residents rotate at DHMC on the 3 clinical services. During each quarter they rotate on each team with increased responsibility assigned to them each time they rotate on a service. While assigned to a particular team residents attend clinic and operate with the teams attendings. Continuity of care occurs by seeing new patients in clinic, operating on and caring for the same patient post op and then seeing patients return to clinic for follow-up.
Goals:
a) Obtain foundation of knowledge in urologic disease, including basics of renal physiology, adrenal physiology, neurourology and urodynamics, infertility, embryology, pediatric urology, female urology, stone disease, general male urology, and oncology with emphasis on office urology and diagnostic procedures.
b) Gain experience in pediatric urology disease evaluation and managment
c) Learn basics skills of endoscopy of the lower urinary tract.
d) Gain experience in abdominal and flank cases.
e) Gain experience in percutaneous endouroloigc procedures.
f) Develop teaching skills to assist in the education of medical students and interns
g) Initiate study of clinical research principles
h) Refine interpersonal skills with support personnel.
Objectives:
a) Demonstrate knowledge of fundamental principles of urologic disease and pathophysiology through didactic lectures and self study.
b) Perform cystoscopy, bladder biopsies and ureteral catheter insertion.
c) Perform urethral dilation and direct vision urethrotomies
d) Perform more complex lower urinary tract endoscopic procedures, such as TUR biopsies of the bladder
e) Gain experience with ureteroscopy and laser lithotripsy
f) Obtain experience and technical expertise in scrotal, inguinal, vaginal and other minor urologic surgery. Perform abdominal and flank wound opening and closing and as the year progresses perform an increasing amount of the case in major abdominal or flank cases.
g) Develop basic laparoscopic surgical skills such as instrument handling and knot tying.
h) Gain experience in pediatric urology with particular emphasis on procedures such as orchiopexy and hernia repair.
i) Provide pre and post-operative care for urology patients.
j) Obtain skill in urologic trauma care including the evaluation, monitoring, surgical care and post-operative care of acute trauma
k) Evaluate fund of basic urologic knowledge through the in-service exam with an expected performance about the 50th percentile of the national average.
l) Identify and plan a clinical research project for the 2nd year.
m) Evaluate progress of urologic knowledge through in-service examination with expected performance above the 50th percentile nationally.
n) Present a lecture at Urology conference.
o) Present and discuss cases at Radiology rounds, M& M conference and Tumor Board.
p) Work effectively with support personnel in urology.
Second Year
During the second year the resident spends six months in research and six months on a clinical rotation that consists of transplant, ultrasound, urodynamics and pathology. During the clinical rotation the resident spends a half day each week in clinic where they see new general urology patients and follow patients that they have seen previously. This clinic is supervised by an attending urologist.
The resident also spends a half day per week going to transplant clinic where they are involved in the work-up of new patients and the follow-up of patients that they have operated on. They participate in donor nephrectomy and in transplantation, particularly the neocystotomy.
The resident attends the elevated PSA clinic that is held 3-5 mornings per month where they assess new patients and perform transrectal ultrasounds and prostate biopsies.
The resident learns how to perform and interpret urodynamics by participating in an adequate number of urodynamic studies.
Knowledge of GU pathology is increased by self study.
General Goals:
a) Learning in the second year will focus on research, transplantation, ultrasound, urodynamics and pathology.
b) Expand depth and scope of knowledge of urologic disease.
c) Develop problem solving skills for diagnosis of urologic conditions.
d) Refine interpersonal skills with support personnel.
General Objectives:
a) Demonstrate knowledge of fundamental principles of urologic disease and pathophysiology through didactic lectures and self study.
b) Evaluate fund of basic urologic knowledge through the in-service exam with an expected performance about the 50th percentile of the national average.
c) Present a lecture at Urology Conference.
d) Present and discuss cases at Radiology Rounds, M& M Conference and Tumor Board.
e) Work effectively with support personnel in urology.
Transplantation
Specific Goals:
a) Become familiar with the biology of histocompatibility.
b) Learn the process of donor and recipient selection, renal perfusion and preservation and the procedure of transplantation.
Specific Objectives:
a) Obtain exposure to pre and post-transplant patients in transplant clinic.
b) Perform donor nephrectomy and ureteroneocystotomy under the supervision of the transplant surgeon.
Radiology
Specific Goals:
a) Understand the role, techniques and complications of transrectal ultrasonography of the prostate and prostate biopsy.
Specific Objectives:
a) Perform transrectal ultrasonography and prostate biopsies under the supervision of attending staff.
b) Present a didactic lecture on a radiologic topic at GU Conference.
Urodynamics
Specific Goals:
a) Understand the indications for urodynamic studies.
Specific Objectives:
a) Perform and interpret a urodynamic study of a pediatric patient, a man with lower urinary tract symptoms, a women with incontinence and a patient with a neurogenic bladder.
b) Present a didactic lecture on a urodynamic topic at GU Conference.
Pathology
Specific Goals:
a) Obtain exposure to GU Pathology.
Specific Objectives:
a) Learn fundamentals of GU Pathology.
b) Present a didactic lecture on a pathology topic at GU Conference.
Research
Goals:
a) Interpret, initiate, and complete basic urologic research.
b) Expand understanding of clinical research, including trial design, biostatistics, epidemiology and outcomes research.
Objectives:
a) Interpret, initiate and complete a basic research project in urology either based on laboratory research or outcomes research with a scientific mentor in Urology or another Dartmouth researcher with special expertise.
b) Learn basic principles of study design and biostatistics through initiation of basic and or clinical research.
c) Work effectively with research graduate and post graduate students, laboratory technicians, managers and research colleagues.
d) Submit abstract to a regional and a national meeting.
e) Submit manuscripts for publication on at least one research topic.
f) Evaluate knowledge base by in-service exam with expected performance above the 50th percentile nationally.
Third Year
The third year residents rotate at DHMC on the three clinical services during a six month period of time. Rotations are ideally two months in duration but while we have an uneven number or residents the rotations are of one month duration. As in the first year the resident has increased responsibility assigned to them each time they rotate on a service. While assigned to a particular team residents attend clinic and operate with the attendings. Continuity of care occurs by seeing new patients in clinic, operating on patients and caring for them post op and then seeing patients return to clinic for follow-up.
Third year residents do a six month rotation in Concord. In Concord they work with six different attendings. Care is taken to insure that continuity of care occurs by having the resident attend clinics in addition to operating.
Goals:
a) Expand depth and scope of knowledge of urologic diseases.
b) Develop problem solving skills for diagnosis of urologic conditions.
c) Gain experience in complex reconstructive surgery including pediatrics.
d) Expand surgical experience in oncology and laparoscopy.
e) Refine interpersonal skills with support personnel.
f) Learn issues related to private practice of urology and managed care.
g) Gain additional expertise in a private practice setting in both in-patient and out-patient care at Concord Urology and Concord
Objectives:
a) Demonstrate knowledge of fundamental principles of urologic disease and pathophysiology through didactic lectures and self study.
b) Refine endoscopic, open and laparoscopic surgical skills.
c) Evaluate fund of basic urologic knowledge through the in-service exam with an expected performance about the 50th percentile of the national average.
d) Present a lecture at Urology Conference.
e) Present and discuss cases at Radiology Rounds, M& M Conference and Tumor Board.
f) Work effectively with support personnel in urology.
Fourth Year - Chief Resident
The Chief residents rotate at DHMC for six months and at the VA for six months. While we have an uneven number of residents each Chief resident is assigned for one month to one of the three clinical services. During this time and particularly during the other three months at DHMC the Chief resident oversees all three clinical services. The chief resident is given increased responsibility by the attendings in caring for in patients and is ideally the operating surgeon under supervision on the most complex cases. Continuity of care occurs by seeing new patients in clinic, operating on patients and caring for them post-op and then seeing patients return to clinic for follow-up.
The Chief resident at the VA oversees the in-patient and outpatient urology service at the VA. The Chief resident is the operating surgeon under supervison on all cases. Continuity of care occurs by seeing new patients in clinic, operating on patients and caring for them post-op and then seeing patients in follow-up in clinic.
Goals:
a) Obtain proficiency in entire spectrum of pathophysiology of urologic disease.
b) Mature in surgical expertise as primary surgeon.
c) Demonstrate administrative skills and responsibility in organization of the service.
d) Refine interpersonal skills with support personnel.
e) Supervision of entire resident team.
f) Refine teaching skills as a lecturer.
g) Refine interpersonal skills with support personnel.
Objectives:
a) Master sophisticated aspects of urologic disease physiology, diagnosis and decision making in preparation for the qualifiying exam (Part 1) of the Urology Boards.
b) Organize teaching conferences within the Section in conjunction with the Program Director. Administer the conferences including; publicizing the conference on a weekly basis, assigning presenters for M&M and Radiology Conference, submitting a list weekly to radiology of cases to be presented at Radiology Conference, and completing the records for M&M Conference and delivering them to the administrative assistant.
c) Develop resident call schedule and insure that the schedule is maintained to that all residents are in compliance with the ACGME rule of one day off in seven over an average of 28 days.
d) Supervise in-patient care at DHMC as the chief of the service with faculty supervision.
e) Delegate responsibilities to junior residents as appropriate.
f) Supervise in-patient and out-patient care at the VA as chief of the service with faculty supervision.
g) Compare academic practice at a multi-specialty clinic to a Veterans Medical
h) Submit at least one manuscript or chapter for publication on a clinical or basis science research topic.
i) Present a lecture at Urology Conference.
j) Present and discuss cases at Radiology Rounds, M& M Conference and Tumor Board.
k) Refine surgical skills in most complex cases with a particular emphasis on oncology and laparoscopy (including radical prostatectomy open and lap, cystectomy with cutaneous and continent diversion, partial nephrectomy, IVC thrombectomy, retroperitoneal lymph node dissection, reconstructive pediatrics.
l) Refine surgical skills in transurethral resection of prostate.
m) Evaluate progress of urologic knowledge through in-service examination with expected performance above the 50thpercentile nationally.
n) Present a lecture at Urology Conference.
o) Present and discuss cases at Radiology Rounds, M& M Conference and Tumor Board.
p) Work effectively with support personnel in urology.
VA
Specific Goals:
The Chief Resident is responsible for the entire service.
DHMC
Specific Goals:
The Chief Resident is responsible for the entire service. Although residents may be assigned to teams during certain rotations, the chief resident will oversee the assignment of cases to insure that cases are assigned to an appropriate level resident while still allowing junior residents to have some participation in complex cases.
B) Goals and Objectives for Each Resident Assignment
1. Dartmouth-Hitchcock A Team Oncology and Laparosccopy
Faculty: Drs. Heaney and Seigne
Goals:
a) Gain knowledge in pre and post-operative care, intraoperative technical skills with an emphasis on urologic oncology patients.
b) Develop a knowledge base for decision making regarding use of endourologic surgical therapies for urologic malignancies.
c) Learn basic principles of urologic laparoscopic surgery.
Objectives:
Following rotations as a first and third year urology resident on the Oncology service the resident will be able to:
a) Completely manage postoperatively patients who have undergone large open or laparoscopic urologic oncologic procedures, such as radical nephrectomy, radical cystectomy with various types of diversion, radical prostatectomy and retroperitoneal lymph node dissection.
b) Use appropriate DHMC care pathways and instruct the interns in the use of these.
c) Recognize post-operative complications and initiate prompt and proper intervention.
d) Increase knowledge of urologic cancer therapies and decision making process regarding relative treatments.
e) Demonstrate increased surgical skills in endoscopy, laparoscopy and open surgery to include oncologic procedures such as transurethral resection of bladder tumors, radical nephrectomy, radical cystectomy with an ileal conduit, and radical prostatectomy.
The Chief resident, in addition to achieving the above objectives will be able to:
a) Demonstrate surgical competency in endoscopy, laparoscopy and open surgery to include oncologic procedures such as endoscopic treatment of transitional cell cancers of the upper and lower urinary tract, radical nephrectomy, partial nephrectomy, radical cystectomy with all forms of diversion, radical prostatectomy, and retroperitoneal lymph node dissection.
2. Dartmouth Hitchcock B Team General Urology, Endourology and Female Urology
Faculty: Drs. Bihrle, Gormley, and Pais
Goals:
a) Develop a knowledge base of general urologic diseases, such as BPH, erectile dysfunction, infertility evaluation of hematuria, and urinary tract infection.
b) Gain outpatient experience with the medical management of common urologic diseases.
c) Gain surgical skills associated with the treatment of general urologic diseases as described above.
d) Gain experience in the spectrum of postoperative care and long-term follow-up of patients after common urologic surgical procedures.
e) Develop a knowledge base for decision making regarding use of endourologic surgical therapies for stone disease and obstruction.
f) Learn basic principles of access to the kidney, percutaneous endourologic procedures, ureteroscopic and cystoscopic endourologic procedures.
g) Expand knowledge of the preoperative evaluation of female incontinence and neurourology.
h) Develop surgical skills in the management of female urologic problems and incontinence.
i) Learn about postoperative management and long-term care of patients with female urologic, incontinence and neurourologic problems.
j) Develop a knowledge base of the management of patients with neurogenic bladders resulting from spinal cord injury.
Objectives
a) Evaluate and treat patients in the outpatient setting who present with general urologic problems including BPH,erectile dysfunction, infertility, stones, hematuria, and urinary tract infection.
b) Demonstrate competency in the surgical treatment of BPH including transurethral resection of the prostate and open prostatectomy.
c) Demonstrate competency in the surgical management of erectile dysfunction including outpatient medical management as well as insertion of penile prosthesis, including pre and postoperative care.
d) Evaluate patients at the time of initial presentation for possible endourologic therapies.
e) Demonstrate competency in access to the upper urinary tract via the bladder.
f) Demonstrate competency in ureteroscopy, including stone manipulation, laser treatment of stones, and treatment of ureteral strictures.
g) Increase knowledge of percutaneous treatment for stone disease and obstruction.
h) Identify and manage postoperative endourologic complications.
i) Follow endourologic patients postoperatively in the outpatient setting with the attending physician.
j) Evaluate patients with incontinence, interstitial cystitis, neurogenic problems, recurrent UTIs, urethral diverticula and fistulas, or pelvic pain with a history, physical examination, additional tests such as urodynamics and formulate a treatment plan that could include behavioral therapy, pelvic floor therapy, biofeedback, medical management or surgery.
k) Demonstrate competency in the surgical treatment of all aspects of female urology.
l) Demonstrate competency in the surgical treatment of neuropathic bladders, including complex lower urinary tract reconstructions.
m) Follow outpatients over the long term with incontinence, interstitial cystitis, pelvic pain and non-neurogenic and neurogenic voiding dysfunction.
n) Evaluate acute spinal cord injury patients and initiate management.
o) Evaluate and manage urologic aspects of patients with long standing lower urinary tract dysfunction secondary to spinal cord injury.
Dartmouth-Hitchcock C Team Pediatric Urology
Faculty: Drs. Herz, Merguerian, and McQuiston
Goals:
a) Expand knowledge base in the medical and surgical evaluation and treatment of pediatric urologic diseases.
b) Learn surgical skills associated with pediatric urologic surgeries.
Objectives:
a) Evaluate patients with pediatric urologic disease.
b) Demonstrate competency in the surgical management of common pediatric urologic surgical problems such as vesicoureteral reflux and cryptorchidism.
c) Obtain surgical skills in the treatment of complex pediatric problems such as hypospadius, congenital anomalies and major urinary tract reconstruction.
Concord
Faculty: Drs. Fabozzi, Green, Santis, Schwaab, Snyder, Trand Yap
Goals:
a) Obtain an understanding of the practice of urology in a private practice setting.
b) Increase surgical skills in a broad spectrum of urologic diseases.
Objectives:
a) Demonstrate competency in a broad spectrum of urologic surgery.
b) Participate in outpatient care in the private offices and the outreach offices of a private practice urology group.
c) Understand the advantages, disadvantages and challenges facing urologists in a private practice setting.
VA Medical Center White River Junction Chief Year
Faculty: Dr. Bihrle
Goals:
a) Gain experience with a more autonomous role in the management of the entire spectrum of urologic patients in the VA setting.
b) Develop administrative skills in patient care management in a more independent fashion.
c) Expand surgical experience with a broad spectrum of urologic diseases.
Objectives: By the end of the rotation, the resident will be able to:
a) Organize and staff the VA out-patient clinics with faculty supervision on site for each clinic.
b) Perform a broad spectrum of urologic procedures ranging from oncology, stone disease and endoscopy and general urologic procedures.
c) Manage the in-patient and post-operative care after common urologic procedures.
Two visiting professors are invited each year to participate in the program's didactics. A conference schedule is published at least three months in advance. The following conferences occur:
- Uroradiology Conference and Urology Teaching Conference 1 hour each week
- Morbidity and Mortality Conference 1 hour monthly
- Uropathology 2 hours monthly
- Urodynamics Seminar 1 hour monthy
- Journal club 3 hours monthly
Summary of the Four Year Curriculum (in months)
In-Patient/Out-Patient Mary Hitchcock Memorial Hospital
Lebanon
Oncology
In-Patient/Out-Patient Mary Hitchcock Memorial Hospital
Lebanon
Female Urology
Reconstruction
In-Patient/Out-Patient Mary Hitchcock Memorial Hospital
Lebanon
Pediatric Urology
In-Patient/Out-Patient
Veterans Affairs
White River Junction
Research and Transplantation Dartmouth Medical
Lebanon
Concord Urology
PGY3
4
4
4
0
0
0
PGY4
0
0
0
0
12
0
PGY5
2
2
2
0
0
6
PGY6
6
6
0
0
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Caseload
The resident during the three clinical years of urology training experiences an overall caseload which remains in the 50th percentile nationally. Primary urologic surgery such as transurethral surgery, incontinence surgery, and oncology is in a higher percentile. Surgery is done predominantly with the resident as the operating surgeon and the responsible surgeon in constant attendance.
There will be a major change to the curriculum for 2009-2010. The 1st years will do 6 months at DHMC, 3 months in Concord, and 3 months of Pediatrics. The 2nd years will remain the same. The 3rd years will do 6 months at the VA, 3 months in Concord, and 3 months of Pediatrics. The entire 4th years will be at DHMC with 6 months assigned as the Chief.
| Caseload (2005-2006) | ||||||||
Total by Residents | ||||||||
'05-'06 | '06-'07 | '07-'08 | ||||||
| Female Incontinence | 60 | 47 | 78 | |||||
| Radical Prostatectomy | 75 | 78 | 133 | |||||
| Radical Cystectomy | 14 | 25 | 35 | |||||
| Renal Surgery | 70 | 62 | 136 | |||||
| TURP | 65 | 55 | 155 | |||||
| TURBT | 120 | 151 | 246 | |||||
| Ureteroscopy | 155 | 150 | 259 | |||||
| Hydrocel | 38 | 16 | 64 | |||||
| Hypospadias | 38 | 20 | 25 | |||||
_______________________________________________
Facilities
The urologic clinic in the Lebanon campus is contiguous with the faculty offices and includes an ambulatory cystoscopy suite and a urodynamic suite with state-of-the-art pressure and electro-physiological monitoring equipment as well as fluroscopy. Transrectal ultrasound is done in conjunction with the imaging department.
The Veterans Affairs Hospital has an integrated out-patient and in-patient urological service.
