Orthopaedic Residency Program

University of Maryland Orthopedic Program: Pediatric Orthopaedic Rotation at Sinai Hospital

Description of Rotation

The UMMS Orthopedic Resident rotation at Sinai Hospital is set up for the UMMS resident to work directly with Dr. John E. Herzenberg and Dr. Shawn Standard. Both are fellowship trained pediatric orthopaedists, and members of the POSNA, AAOS, and the Limb Lengthening and Reconstruction Society. Both maintain a full time, hospital based practice. Both doctors practice in the Rubin Institute for Advanced Orthopedics, within the International Center for Limb Lengthening, all located within Sinai Hospital. Dr. Herzenberg serves as Director of the ICLL, and as Head of Pediatric Orthopaedics at Sinai Hospital.

The resident rotation in the PGY-4 year for 10 weeks, (separate from the UMMS Pediatric Orthopedic rotation at Johns Hopkins Hospital). This rotation is combined with the UMMS Musculoskeletal Tumor rotation at Sinai Hospital in an 80/20 split. This means that the UMMS resident spends one day per week (usually Monday) on the Tumor Service, and the other four days per week (Tue-Fri) on the Pediatric Orthopedic Service. In addition to the UMMS Peds Ortho residents, there are also podiatry residents and limb lengthening fellows rotating through the service. In contradistinction to these other residents/fellows, the UMMS Peds Ortho Residents are given first priority on all peds ortho cases.

The residents spend 2 days per week in the operating room and 2 days per week in the outpatient offices with 3 attending surgeons. The out patient clinics include new patients, follow-ups, and a special Club Foot Clinic. The resident is mandated to the 80 work week but takes on call duties (surgical, postop followup) with each surgeon on a regular schedule. A weekly 1 hour teaching lecture for residents and fellows is supervised by Dr. Herzenberg, with guest lectures on a variety of orthopaedic topics, but almost all of them pediatric orthopaedic in nature. Examples of lectures this past year have included Pediatric Spinal Deformity, SCFE, Elbow Fractures in Children, Fractures about the knee in Children, Fibular Hemimelia, Dwarfism, Radial Club Hand, Perthes Disease, Congenital Pseudarthrosis of the Tibia, Congenital Femoral Deficiency, Torsional Deformities in Children, Spatial Frame Applications in Children, Club Foot, Common Foot Problems in Children, BrachTarsal Coalition, Angular Deformities in Children, Analysis of Deformity, DDH, and Cerebral Palsy.

Other conferences include a weekly Surgical Indications (preoperative) Conference, and Monthly Orthopaedic Grand Rounds. Residents prepare case presentations for the weekly preoperative conference. The surgical experience is broad and pediatric focused. Dr. Herzenberg’s practice is 85% children, with the other 15% being adults with angular deformities, limb length discrepancy, non-unions, and residual of pediatric orthopaedic problems (such as adults with cerebral palsy). Dr. Standard’s practice is 100% children. The residents are always assigned to pediatric cases in the OR. In clinic, they always pick up the pediatric patients, even if that means taking patients out of order. Exposure to the ER is minimal, though consults for pediatric fractures and in-patient pediatric consults are often fielded by Dr. Standard, with help from the resident.

Length:	10 weeks of PGY-4 year
Location:	Sinai Hospital of Baltimore
Primary Supervisors:	John Herzenberg, M.D. (Office: 410-601-9562) Shawn Standard, M.D. (Office: 410-601-9772)

Patient Care

Competency

Residents must be able to provide patient care that is compassionate, appropriate, patient-centered and effective for the diagnosis treatment of orthopaedic problems and the promotion of health. Residents are expected to:

Objectives

Demonstrate caring and respectful behaviors (verbal and non-verbal) with patients and families.
Elicit appropriate patient medical history information using effective questioning and listening skills.
Efficiently assess pediatric orthopaedic patients and document clinical findings in a clear and quantitative form, including range of motion examination, strength assessment, and the results of standard tests such as the Ortolani maneuver, the Ober test, the Ely, the Galeazzi, the Silverskiöld, and the Trendelenburg.
Properly evaluate and treat common pediatric orthopaedic conditions such as Perthes, slipped capital femoral epiphysis, flat foot, osteomyelitis, and hip dysplasia.
Properly evaluate and be familiar with treatment of more complex pediatric orthopaedic conditions such as osteogenesis imperfecta, neuromuscular disorders, spinal deformity, and congenital deformities of the upper and lower extremities.
Be exposed to severe and neglected problems such as the sequelae of sepsis and untreated rickets.
Formulate appropriate treatment recommendations, including non-surgical and surgical treatment goals for the above conditions.
Demonstrate proper casting techniques including Ponseti and spica casting.
Demonstrate a working knowledge of external fixation for correction of pediatric deformities such as Blount disease, and leg length discrepancy.
Understand use of pediatric growth charts, Multiplier Method, and predictions of height and limb length discrepancy.
Demonstrate skill in analysis of long bone deformity and preoperative planning.
Demonstrate appropriate preoperative evaluation, including consent and surgical site marking for surgical procedures.
Residents are instructed by our attending staff and physician assistants in the technique of informed consent and post-operative guidance for parents and patients.
Demonstrate appropriate postoperative management, including adeptly close surgical wounds, place drains, and apply appropriate post surgical dressing.
Demonstrate knowledge of potential outcomes including complications of treatment.

Medical Knowledge

Competency

Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to be able to:

Objectives:

Quantitatively assess growth potential and utilize this knowledge to devise a treatment plan that optimizes equality of limb length at the cessation of growth.
Understand and utilize the common classification systems applied to congenital malformations and perform common surgical procedures such as simple syndactyly release and removal of polydactylic digits.
Understand and use classification systems for Perthes and SCFE.
Understand spectrum of club foot, and variations in its treatment.
Feel comfortable with evaluation and treatment of common torsional anomalies, and bowing.
Master the technique of epiphyseodesis and hemi-epiphyseodesis.
Understand evaluation and treatment of common pediatric fractures.
Appropriately evaluate orthopaedic literature and present this literature in case presentations.
Cite levels of evidence in the orthopedic case-driven medical literature.
Understand and apply the basic biomedical statistics in evaluation of the medical literature.
Demonstrate the ability to select treatment based on evidence from literature.

Practice- Based Learning and Improvement

Competency

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to:

Objectives:

Evaluate one's own knowledge, incorporating feedback from others
Modify self-directed learning appropriately including feedback provided from the OITE results.
Appraise and assimilate evidence from scientific studies to enhance patient care, especially as it relates to pediatric orthopaedic diagnoses and treatments.
Effectively use information technology to access and manage patient information.
Effectively use information technology and other resources to support one’s own ongoing self-education (DVDs, etc)
Contribute to discussions concerning patient care with other health care professionals, attendings, and consultants
Attend and participate in didactics and rounds
Produce a pre-rotation list of specific goals and objectives for the rotation; share these goals with the faculty; track progress towards achieving these goals and objectives; and report on the accomplishments.

Systems Based Practice

Competency

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as be able to effectively call on other resources in the system to provide optimal health care. Residents are expected to:

Objectives

Collaborate with and maintain appropriate professional attitudes and behaviors toward other medical professionals and allied health personnel
Assess how one’s own actions affect others, especially in the pediatric setting
Integrate the care of pediatric patients in inpatient settings
Use diagnostic and therapeutic procedures appropriately and judiciously
Evaluate risks, benefits, limitations, and costs of patient care
Provide data for conferences to positively affect patient care
Participate in clinical pathways designed to improve patient outcomes
Serve as patient advocates in dealing with system complexities
Serve as patient advocates for quality patient care
Work effectively with other services, social workers, and case managers

Professionalism

Competency

Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

Objectives

Exemplify and display an observable respect and compassion toward patients
Exemplify reliability, punctuality, integrity and honesty
Accept responsibility for one’s own actions and decisions
Apply sound ethical principles in medical practice, including issues of patient confidentiality, informed consent, provision for the withholding of care, and interactions with insurance companies or disability agencies
Consider the effects of personal, social, and cultural factors in the disease process and patient management
Demonstrate non-judgmental sensitivity and responsiveness to the age, culture, disability status, and gender of patients, families and colleagues

Interpersonal and Communication Skills

Competency

Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:

Objectives

Establish trust and maintain rapport with patients and families
Complete dictations and chart notes in a timely manner
Discuss diagnoses, prognoses and treatment options clearly and accurately to patients
Synthesize information and present clinical and diagnostic information clearly to colleagues and attendings
Utilize effective listening skills
Communicate and interact with staff/team in respectful, responsive manner

Teaching Methods

PGY-4 residents on the Pediatric Orthopaedics service interact directly with the faculty. Teaching is by case-method with didactic support in the form of lecture and Socratic review of resident reading assignments in topics in pediatric orthopaedic surgery. Residents on the Pediatric Orthopaedics rotation at Sinai are required to attend the Friday morning teaching conference at University Hospital.

Assessment Method (residents)

Resident performance will be subject to daily observation and evaluation in the operating room, and the clinic; the attending staff will evaluate each resident at the middle and end of each rotation, using the eValue system. These reviews are reported directly to the UMMS Orthopedic Surgery Residency Director.

Assessment Method (Program Evaluation)

All residents are urged to voice their opinions where the program (or any part of it) is concerned. Residents are required to evaluate the program (anonymously) at the conclusion of their rotation.

Level of Supervision

Under supervision of the attending staff, residents will provide inpatient and outpatient care for children with pediatric orthopaedic disorders. Duties will include outpatient assessment, history, and physical examinations, pre and post operative ward care, supervised performance of surgical and non-surgical procedures, and participation in outpatient and outreach clinics.

Outpatient

Supervision
Resident outpatient supervision is provided by the attending surgeon who is in attendance; all new cases are presented to the attending surgeon after a diagnosis and treatment plan is formulated by the resident. Additions and revisions are made as indicated after presentation to the attending surgeon and examination of the patient is completed together. The attending and resident review and examine all those patients being seen on a return basis together. At the end of each clinic, the PACS system films for the day are reviewed, so that the UMMS resident will learn from those cases that were seen by other residents/fellows.
Progressive Responsibility
The resident is given the opportunity to assume increasing responsibility in the outpatient setting by allowing him/her to diagnose and manage patients based upon his experience and demonstrated competence. Full attending supervision is provided and each plan is confirmed by direct participation of attending and resident in patient care.

Inpatient

Supervision
Resident inpatient supervision is provided by the attending surgeon. All cases are supervised by the surgeons and the residents are required to evaluate the patient, establish a working diagnosis and formulate a treatment plan which is presented to the attending. The resident then follows his patient with the attending surgeon on a daily basis until the patient is discharged. Follow-up care is provided in the outpatient clinics.
Progressive Responsibility
Each resident is given the opportunity to assume increasing responsibilities on inpatients assigned to his care, based upon his/her level of experience and competence. Direct supervision is provided by appropriate attending surgeon during all phases of the educational process.

Operative

Supervision
Supervision in surgery is provided in all instances. The attending physician is physically present for all surgeries from start to finish.
Progressive Responsibility
Progressive responsibilities are determined based upon the complexity of the case and the demonstrated competence of the resident. Portions or all of the surgery may be performed by the resident with direct attending surgeon supervision of all facets of care.

Educational Resources

List the educational resources

Educational Conferences:
Weekly Tuesday morning pediatric conferences, weekly Thursday morning preoperative indications conference, and weekly Friday morning teaching conference (UMMS). Monthly Orthopaedic Grand Rounds (fourth Tuesday of each month).

Library Space/Resources:
The basic textbook for the rotation is Wenger and Rang’s “Art and Practice of Children’s Orthopaedics”, which is made available to the resident at the start of his rotation. There is also a comprehensive pediatric orthopaedic syllabus that each resident is expected to read. Residents at Sinai have access to peer reviewed journals and textbooks 24/7 via widely available internet access throughout the hospital, including on-line access to most journals and textbooks. Resources are available in the RIAO/ICLL at Sinai Hospital and the medical library of the hospital. A video library which contains instructional materials for limb lengthening and reconstruction techniques.

Research Support/Personnel:
Full support is available to residents for clinical research at Sinai Hospital. This includes two research assistants in the ICLL, and the RIAO publishing team, which includes a medical editor, medical illustrator, graphic artist, and photographer.

This page was last updated on: April 20, 2009.

For more information about UM Orthopaedics or to make an appointment, call toll-free at 1-877-771-4567 or 410-448-6400, send us an e-mail or complete our secure contact form.