THE HARVARD SHOULDER SERVICE
HARVARD FELLOWSHIP GUIDELINES

I. MISSION STATEMENT:

Our goal is to provide the highest quality of care for routine and complex problems affecting the shoulder, and to do so regardless of a patient's socioeconomic situation. Furthermore, the Harvard Shoulder Service maintains a strong commitment to education of residents, fellows, and visiting orthopaedists, and for the advancement of surgical and non-surgical treatment based on research initiatives.

II. ATTENDINGS:

Jon J.P. Warner, M.D.: Chief, Harvard Shoulder Service (at Partners) Peter J. Millett, M.D., M.Sc.: Harvard Shoulder Service, Attending at BWH & MGH Thomas Gill, M.D. (Also Sports Medicine Service, MGH) Thomas Holovacs, M.D. (Also Sports Medicine Service, MGH) Bertram Zarins, M.D. (Also Sports Medicine Service, MGH)

III. INTRODUCTION:

The Harvard Shoulder Service at Partners is based at both the MGH and the BWH. While these services have different rotations and resident assignments at each institution, the overall goal of the shoulder service is to provide an in-depth and coordinated educational experience for residents and fellows. This experience will provide exposure to a deep and broad clinical experience in the management of shoulder problems ranging from shoulder instability to arthritis. Furthermore, our goal is to work in collaboration and coordination with the Sports Medicine Rotation at the MGH to ensure a balanced experience for the residents both inside and outside of the operating room.

The commitment of this service is to not only provide an opportunity for residents and fellows to observe the diagnosis and treatment of these problems, but to also allow a graduated level of responsibility in an office and operating room setting.

There are currently three residents assigned to the Sports Medicine and Shoulder Rotatotion. Though these residents have different rotations it is expected that they function to assist one another in cross coverage of clinical responsibilities. Furthermore, there may be overlap coverage responsibilities in the operating room from time to time. A Senior and Junior Resident are assigned to the Sports Medicine Service at the MGH and Dr. Bertram Zarins is in charge of the curriculum and coverage responsibilities; however, a coordinated rotation schedule is listed in this document as well. The Shoulder Resident is a senior resident who will work both at the MGH and BWH with Drs. Warner and Millett respectively. Occasionally the Sports Medicine Senior or Junior resident will also cross cover Peter Millett. This will be based on vacations schedules and through agreement by the attendings.

IV. SCHEDULES

The following clinical rotation on the Shoulder Service is coordinated with responsibilities for the residents:

A. Residents' and Fellows' Schedules:

(SEE EXHIBIT 1)

V. SHOULDER CONFERENCES:

MGH
The Shoulder Service shares a conference schedule with the Sports Medicine Service, and this schedule is based on a six month cycle. These conferences are held each Thursday at 8:00 AM (except when Mortality and Morbidity Conference is scheduled) in the Smith-Peterson Conference Room on White 6. The conference schedule is distributed through Dr. Zarins office and is available to each resident at the beginning of his / her rotation. In general, 4 session on shoulder are held during each six-month cycle. Shoulder Conferences are case-based presentations and will employ the Socratic method of teaching. The Shoulder Fellow (I.C.S.F.) is principally responsible for preparation of each conference. The remainder of the conference sessions deal with topics in Sports Medicine. Journal Club will also be held on a regular basis. Residents and fellows will be responsible for discussion of assigned articles.

The Shoulder Conference format is case presentation with questions directed to all residents, fellows, and attendings. The intention is to highlight key aspects of diagnosis and decision-making and then to review the range of treatment possibilities. Clinical outcome can then be correlated to the method of treatment chosen. Controversy and difference of opinion is seen as a useful educational method. Residents will be given a reading list as well as a textbook on Sports Medicine and Arthroscopy and a CD-ROM on Selective Exposures for Shoulder Surgery. These are intended to be references for the conferences and a basic understanding of shoulder pathology is therefore expected of all residents when discussing cases in conference.

Topics routinely covered are:

Shoulder Instability
Rotator Cuff disease
Shoulder Arthritis
Nerve Injuries
Shoulder Stiffness
Shoulder Fractures

In addition, the Shoulder Service will hold an "Indication Conference" on Tuesday afternoon at the end of Dr. Warner's Clinic (around 5-6PM) during which all cases to be operated on that week will be discussed. This will be in the Clinic area.

BWH
A combined MRI / arthroscopy conference that involves the participation of the shoulder service and the musculoskeletal radiologists will be held on a monthly basis. The residents are welcome to attend and expected if their clinical schedule allows. This is an excellent opportunity learn about advanced medical imaging and to improve diagnostic acumen. Dr. Millett has information about this conference.

VII. GOVERNANCE AND LINES OF RESPONSIBILITY

A. GENERAL INFORMATION
The shoulder service is under the direction of Dr. Jon J.P. Warner.

While the Shoulder Resident is primarily responsible for care of all Shoulder Service Patients, it is expected that there is cross coverage with the Sports Medicine Residents as needed. The Shoulder Resident or his designate is expected to make daily rounds and discuss patient issues with the Shoulder Fellow or with Dr. Warner or Millett. Dr. Holovacs patients are to be covered by the Sports Medicine Service.
Residents who are participating in surgery are expected to find out in advance the nature of the surgeries to be performed and then to make an effort to read about these cases. This can be accomplished by discussion with the Shoulder Fellow or contacting Christine Simmons, the Surgical Coordinator for Dr. Warner. For Dr. Peter Millett's cases at BWH contact Jane Lawlor Ortiz, the surgical coordinator for Dr. Millett.
Reference information including a reading list, textbook, and CD-ROM(s) will be provided at the start of the rotation when the residents come to Dr. Warner's office on Tuesdays.

As the resident begins his(her) clinical rotation they will be asked to view two videotapes on Physical Examination of the Shoulder in Dr. Warner's office, prior to seeing patients. They will then see patients with Dr. Warner as well as evaluate and present new patients to Dr. Warner.

In addition, there are a full spectrum of powerpoint presentations available on the Fellow's Computer for review and CD-ROMS and videos of surgical cases will be made available for all residents. This is optional for all residents.

Residents are expected to be present at the beginning of each case and to assist in positioning of the patient. There will be no responsibility on the part of the resident to dictate operative notes, as Drs. Warner and Millett will dictate their own notes. A copy of each operative note will be sent to each resident for cases in which they participate.

B. JUNIOR RESIDENTS

The schedule (Exhibit 1) shows coverage responsibilities for all residents.

Most of your exposure will be through Dr. Holovacs as well as through rotations on the Sports Medicine Service.

(The shoulder resident is expected to make rounds on patients at BWH however, when at MGH this may not be possible. To insure in-house coverage when the PGY-5 resident is at MGH, Dr. Millett and Warner's inpatients at BWH will be covered by the PGY-2 resident from Dr. John Wright's service. In the event the PGY-2 resident is not in-house, then the 1820 resident is responsible for coverage of Dr. Millett's patients.

B. SHOULDER SERVICE RESIDENTS

The schedule (Exhibit 1) shows all resident coverage responsibilities.

The Shoulder Service Resident on the service will have a principal role on the service. This resident will coordinate the clinical and academic activities and have the opportunity to work with both Dr. Warner and Millett.

1. Responsibilities with Dr. Warner

Office Experience: This is identical to that described for the Junior Resident, with the same expectations for development of diagnostic acumen.

Operative Experience: The operative experience is primarily divided into Arthroscopy of the shoulder and Reconstructive (both primary and revision) surgery. With Dr Warner, the former is performed on Wednesdays in the SDSU, and the later on Thursdays in the Main O.R. On Wednesday afternoon, the resident will have the opportunity to perform and assist shoulder arthroscopy, and on Thursdays he / she will have the opportunity to perform and assist in open reconstructive surgery of the shoulder. On both days the Resident will work under the guidance of Dr. Warner and the Shoulder Fellow.
The operative experience may vary from resident to resident and will be based on the following criteria: knowledge of the problem being treated (read about it prior to coming to the O.R.), surgical skill level, and consistent attendance for operative cases. The range of cases which the resident is likely to observe, assist with, and perform surgery include the following:

ARTHROSCOPIC

RECONSTRUCTIVE

2. Responsibilities with Dr. Millett
Currently, the Shoulder Service Resident will work with Dr. Millett according to the schedule (Exhibit 1).

Rarely, patients from the Surgi-center may need to be admitted to BWH at the end of the day for anesthetic or pain-related issues. The resident on-call will be notified and will contact admitting so that the patient may be directly admitted to the floor. Dr. Millett should also be notified.

Clinical Duties
Residents will be responsible for all clinical coverage of Dr. Millett's patients when they are admitted to the hospital. This includes daily rounds, discussion of care with Dr. Millett, management of discharge including prescriptions and dictation of discharge summaries. Office expectations are as listed above. When the resident is at MGH with Dr. Warner coverage needs to be arranged in terms of rounding and care of Dr. Millett's patients at BWH.

Dr. Millett wants to be notified of important clinical activities on his patients and should be updated at least once daily either through text page, email, or direct discussion. Dr. Millett does not mind being contacted at any time and, in fact, prefers to be notified about any and all matters.

Surgical Duties
Residents will assist in the main operating room at BWH. All residents are expected to find out the nature of the planned surgeries and then to make an effort to read about these cases in advance. Dr. Millett will be happy to suggest references if asked.

Residents are expected to take a focused history and to examine all patients before surgery. This is best done in the preoperative area on the day of surgery but may be performed in the office or in the pre-admission testing center. Residents are expected to be punctual and to assist in positioning of the patient. There will be no responsibility on the part of the resident to dictate operative notes, as Dr. Millett will dictate the operative reports. A copy of each operative note will be sent to each resident for cases in which they participate.

The operative experience may vary from resident to resident and will be based on the following criteria: knowledge of the problem being treated (read about it prior to coming to the O.R.), surgical skill level, and consistent attendance for operative cases. The range of cases which the resident is likely to observe, assist with, and perform surgery include the following:

Shoulder

Knee

4. RESIDENT HOURS:

Resident Work hours are limited to 80hrs/week and Residents who are on call are not permitted to engage in clinical care of patients on the following day. Maximum continuous in house duty is limited to 24 hours with a maximum of 6 additional hours to allow for continuity of patient care, transfer of care, didactic activities and outpatient clinics. Residents are expected to alert Drs. Warner and Millett to their schedule during the course of their assigned rotation so that coverage of surgical cases can be planned and the above guidelines adhered to. This should be done by notifying Dr. Warner and Millett by e-mail of their scheduled on call days and their scheduled days off in order to comply with these guidelines. Residents are expected to make it known to Drs. Warner and Millett that they have been on-call the night prior to any clinically scheduled activity.

5. RESIDENT ASSESSMENT AND EVALUATION:

All residents will receive a pre-rotation test to be administered in the first week of their assigned rotation. They will then be asked to take another test in the last week of their rotation. Results of this test as well as overall review of their performance on the rotation will be discussed with the resident at the end of the rotation or shortly thereafter according to convenient scheduling depending on their next clinical rotation experience.

Based on direct observation all residents will be evaluated by the 6 Core Competencies mandated by the RRC:
1. PATIENT CARE
2. MEDICAL KNOWLEDGE
3. PRACTICE-BASED LEARNING AND IMPROVEMENT
4. INTERPERSONAL AND IMPROVEMENT SKILLS
5. PROFESSIONALISM
6. SYSTEM-BASED PRACTICE

In the future a Virtual Reality Shoulder Simulator will be encorporated into the educational program and will also be used as a method to measure arthroscopic skill and correlate with intraoperative performance. This will be for the purpose of gathering information on how better to train these skills, but will not be used to assess the resident's performance in his(her) clinical duties.

7. RESIDENT FEEDBACK ON ROTATION:

Residents will be asked to fill out a form (written or on-line) assessing the quality of their rotation on the Shoulder Service and also commenting on changes they might make to improve the educational experience.

E. THE SHOULDER FELLOWS:

There are currently two fellows with privilages to operate and care for patients. The Intercontinental Shoulder Fellow (I.C.S.F.) spends six months in Boston and six months at the University of Zurich; thus that position changes each six months. This individual works primarily with Dr. Warner. He may, from time to time, work with Dr. Millett or Dr. Holovacs, and there may also be occasions where he scrubs on cases with Dr. Jupiter when interesting Elbow cases are available and then the hand fellow will cross cover in the SDSU with Dr. Warner. This individual, along with the other Shoulder Fellow will also run a Shoulder Clinic every Friday morning at the MGH. On Fridays when Dr. Warner is operating either Shoulder Fellow may come to the operating room to assist while the other runs the clinic. If the Shoulder Resident is available, then both fellows will go to the Shoulder Clinic.

The Partners Shoulder Fellow is selected for six months to work principally with Dr. Millett but also with Dr. Warner on Thursdays and to run a Shoulder Clinic.

The Shoulder Fellows are Instructors in Orthopaedics and will have direct patient care responsibilities for his/her own patients as well as those of Dr. Warner and Dr. Millett. Occasionally, the I.C.S.F. will have a limited license and a J-1 visa and will not have direct clinical responsibilities. In such circumstances he(she) will function as a resident under supervision of either Dr. Warner or Millett. All fellows will be available to assist or admit shoulder trauma cases. The fellow will act as a teacher and assistant for the resident in both the office and the operating room; however, the extent of surgical involvement of each will vary by case according to complexity and skill level of each. The aim is to allow the resident to grow in his / her surgical skill and diagnostic skill during their rotation.

F. VISITING FOREIGN SHOULDER FELLOWS:

Throughout the course of the year there will be many visiting fellows from around the world who will remain as observers for varying period of several days to several months. Two or three will be visiting for the period of 6 months to one year. Their role is principally as observers in the operating room and also in the office setting. They will be involved in research and at times may be a resource for residents in terms of teaching and research projects.

G. FEEDBACK TO FELLOWS:

Fellows will be evaluated by Drs. Warner and Millett at the 3 month and 6 month mark of the fellowship.

VIII. ACADEMIC GOALS AND OBJECTIVES FOR THE RESIDENTS

A. Junior Resident (Sports Medicine Rotation)

Office Experience: The junior resident should be comfortable with performance of a history and physical examination of the shoulder. He/she should be able to appreciate patterns of symptoms and physical findings that will allow an accurate diagnosis. A reasonable differential diagnosis should be possible, and formulation further diagnostic studies and an appropriate treatment plan should also be possible. At the beginning of each rotation the resident will view two videotapes. The first reviews Office Examination of the Shoulder for Instability, and the second reviews Examination of the Shoulder for Rotator Cuff Disease. Each of these is 15 minutes in length. The resident will then see patients during the morning session with Dr. Warner and the Shoulder Fellow. In the afternoon of the first office session, and in subsequent office sessions, the Resident will be expected to perform history and physical examinations on New Patients and then present these patients to either Dr. Holovacs or Dr. Warner. The examination will then be reviewed with Dr. Warner and pathology and treatment then discussed.

Operative Experience: The operative experience for the junior resident is limited to elective opportunity when responsibilities to the Sports Medicine Division are not an issue, as when an attending physician may be away. Otherwise the Senior Resident operates with Dr. Warner on Wednesdays (after Core Curriculum in the morning) and Thursdays.

B. Shoulder Resident:

Office Experience: The senior resident should be comfortable with performance of a history and physical examination of the shoulder. He/she should be able to appreciate patterns of symptoms and physical findings that will allow an accurate diagnosis. A thorough differential diagnosis should be possible, and formulation further diagnostic studies and an appropriate treatment plan should be expected.

Again, at the beginning of the rotation the resident will review the two videotapes that detail the Office Examination of the Shoulder for Instability and the Examination of the Shoulder for Rotator Cuff Disease. Each of these is 15 minutes in length. The resident will then see patients with Dr. Warner orDr. Millett (when Dr Warner is out of town). The Resident will be expected to perform history and physical examinations on New Patients and then present these patients to Drs. Warner and Millett. The examination will then be reviewed and the pathology and treatment discussed.

Operative Experience: The operative experience for the senior resident is with Dr. Millett on Mondays and Fridays, Dr. Warner on Wednesdays and Thursdays. It is expected that the senior residents will have a thorough understanding of the disease and its surgical treatment. Under the guidance of Dr. Millett and Warner the senior resident will be permitted a graduated but supervised level of independence.

By the end of the rotation it is expected that the resident will understand the indications for and the surgical management of shoulder instability, rotator cuff disease, fractures and glenohumeral arthritis. Residents will be expected to perform basic shoulder arthroscopy. They will also be expected to be able to perform the routine surgical approaches to the shoulder including the deltopectoral approach and approaches to the rotator cuff.

IX. EVALUATION OF THE RESIDENTS

Residents will be evaluated on core competencies during their time on the shoulder service. Different methods that will be employed include direct observation and case presentation. Residents will be evaluated on medical knowledge, patient care, interpersonal skills, professionalism, and technical skills. Evaluation of resident participation in conferences will also be employed to assess their overall progress in the rotation. The shoulder service will also encourage the residents to perform self-examination using the AAOS self-assessment examinations and other review question formats.

In the future, we hope to incorporate advanced surgical simulation to measure psychomotor skills so that we can test technical proficiency at the start of and at the conclusion of the rotation.