Educational Methods

This is a hands-on educational fellowship in which the fellow accepts increasing responsibility in patient care and management as he/she acquires experience.

1. Microsurgical Skills: The Microsurgical Laboratory is the first teaching and training ground for new fellows. Basic microsurgical skills are taught to them by an experienced laboratory director who reports directly to the program chairman on the fellows' performance.

2. Operating Skills: Fellows begin as first assistants on all cases and take over increasing responsibility at the discretion of the attending surgeon. New techniques and procedures are demonstrated and fellows are coached through complex dissections on a one-to-one basis.

3. Diagnostic Skills: Fellows are the first to see all patients, acute, routine and emergency. They then present their findings, their diagnosis and recommended treatment to the attending and other members of the resident and fellow staff present.

4. Academic Skills: One fellow is appointed as chief fellow for three to six months and is responsible for the organization and running of daily rounds, the operative schedule and clinic coverage. Routine and complex cases are researched by the fellows from an historical and contemporary standpoint using the department library, the hospital library and computer access to the National Medical Library in Washington. This information is presented by the fellows to the department on rounds, at the weekly division meeting, and when appropriate serves to initiate publications and formal reports.

5. Research Skills: As pointed out elsewhere in this report, all fellows are encouraged to pursue research projects, develop protocols; follow the scientific method and present a final report.

Evaluation Procedures: All fellows' activities are subject to continuous quality assurance surveillance at all levels of their activities throughout the hospital. Each attending continually monitors their activities in the clinic, on rounds, in the operating room and in the research laboratory. Monthly division meetings are held, at which time each fellow's progress is discussed and advancement discussed based on a consensus of the attendings' evaluation.

Goals
To provide an environment in which a qualified and motivated fellow can gain advanced training in hand surgery and reconstructive microsurgery; to stimulate students to become active in clinical and laboratory research, to guide students through the preoperative, operative and postoperative management of routine and complex problems and to set an example for them of ethical, compassionate and high-level care.

Responsibilities of the Fellows

Each in-patient is under the care of a particular attending physician. All fellows are responsible for all patients and must be able to respond to questions from the nursing staff or family about the care and condition of each patient.

When possible, the fellow who works up or admits the patient scrubs as first assistant on the subsequent surgery. He reports to the primary attending after the work-up, discusses the plan of action and evaluates the patient with the attending. If that attending is not present that day, the fellow is obliged to discuss the case with other attendings and as many of his colleagues as possible.

Informed consent is stressed and all patients are counselled on the contemplated procedure, other options, (surgical and non-surgical), the need for blood transfusion, autogenous, donor-designated blood, etc. We stress the use of autogenous blood whenever possible.

The senior fellow scrubbing on the operation is responsible for dictation of the operative report unless instructed by the attending. Standard postoperative orders are reviewed and modified for each case and data sheets are filled out for all microvascular transplants and microvascular replants starting in the operating room. These data sheets are left in the chart and completed as the patient progresses to discharge. These data sheets are then entered into the research computer and are available to all staff members. This material generates abstracts for papers, presentations, and provides a continually expanding data base. Emergency room patents are seen by the fellow on first call, who evaluates the problem and contacts the attending on call who may or may not come to see the patient depending upon the magnitude and severity of the injury.

All potential replant calls are handled by the attending on call who is responsible for summoning the replantation team.

Postoperative patients are seen in the attending's private office in the Medical Center.

One fellow is assigned to each clinic each day and sees all patients before or with the attending. Postoperative care, preoperative planning and new admissions are reviewed together and unusual cases or problem cases are presented to all the fellows and attendings present in the office at that particular time. Unusual or challenging cases are presented to the weekly division conference.

From the above, it can be seen that in-patients, emergency patients, out-patients and clinic visits are carefully monitored at all times by the attending staff on a daily basis.