DScPAS_CO Curriculum.pdf

Technical Exhibit A – Proposed Curriculum Doctor of Science in PA Studies with Specialization in Orthopaedics (DScPA-CO)

Outcomes Measures Q/A

1. Clinical Reasoning/Evaluation and Intervention

a. Written Examination- Case Scenario/Clinical Reasoning Format

(1) Form of Measurement: Director or Program Manager will grade all exams covering specific courses. At the end of OPA-101 through OPA 215 a final exam will be given.

(2) Required Minimum Score: 80%. Exams for OPA-101 through OPA-215 are divided in subsections on specific medical subjects. This enables the Program Manager to determine weakness and strengthens for each subject tested. Students must demonstrate mastery of knowledge and skills, by achieving an 80% minimum score for each area examined.

b. Clinical Supervision- Each rotation will have a written evaluation completed by rotation preceptors. The Resident must, at a minimum meet a satisfactory level of competency during the rotation. The New Innovations Evaluation Form has a ten-point scale divided in unsatisfactory (1-3), marginal (4-6), satisfactory (7-9), and superior 10.

Residents must meet or exceed the satisfactory scale in each of the following areas:

Patient Care, Medical Knowledge, Interpersonal and Communication Skills as well as Professionalism.

c. Research assignment must be completed and evaluated by the Orthopaedic PA Residency Director and course Medical Director.

(1) Project must be suitable for publication.

(2) Minimum passing grade is 80%. The research project will be evaluated on 100 point scoring system, divided into six elements: correct information (0-30 points), knowledge of subject (0-30 points), structure of research (0-10 points), research flow (0- 10 points), style and language (0-10 points), and outcome (0-10).

(3) Project must be presented and defended before a board, to include the Program Director, two other staff members, and one representative from the accrediting university.

d. Mid-term and Final Written Examinations—Case Scenario/Clinical Reasoning Format

(1) Form of Measurement: Director or Program Manager will grade all exams.

Midterm encompasses all course work from OPA-101 to the end of Phase I. Final exam encompasses all course work from OPA 201 through the end of the residency program.

(2) Required Minimum Score: 80% for each subsection.

(3) The midterm is comprised of selected questions previously tested during phase I and is intended to evaluate the baseline knowledge retained by the residents.

(4) The final written exam is divided into sections of orthopaedic subspecialties, which gives data needed to determine strengths and weakness of each student by section. Upon determining weakness, a plan will be implemented for the next matriculating students to strengthen those areas of concern.

e. Midterm and Final Oral Boards-Case Scenario Format

(1) Form of Measurement: Director and Physician Medical Director will evaluate all boards.

(2) All candidates must meet the minimum performance criteria of satisfactory.

The performance criteria are based on a ten-point scale divided in the following manner: unsatisfactory (1-3), marginal (4-6), satisfactory (7-9), and superior 10.

Residents must meet or exceed the satisfactory scale in each of the following areas:

Data Acquisition, Problem solving, Patient Management, Resource Utilization, Health care, Interpersonal relations, Pathophysiology, Clinical competence.

(3) The student will be presented with three individual orthopaedic cases. This is an assessment tool used to evaluate the student’s ability to determine the chief complaint and incorporate information and examination skills learned from didactic teaching and clinical rotations to successfully manage the patient. The Program Director can utilize this data to evaluate the student’s strengths and weaknesses and implement improvements needed for the didactic (Phase I) and subspecialty rotations (Phase II).

f. Oral Presentations during Orthopaedic Service Morning Report

(1) Form of Measurement: Course Director and Physician Program Advisor scores using pre-determined scoring sheet.

(2) Written and verbal feedback from Residents and faculty.

(3) Required Minimum Score: Satisfactory. The performance criteria are based on a ten-point scale divided in the following manner: unsatisfactory (1-3), marginal (4-6), satisfactory (7-9), and superior 10. The candidates must meet the minimum satisfactory score in the following areas: organization, knowledge and presentation.

2. Overall Assessment

a. Each Resident receives an annual performance evaluation report, DA From 1059, Academic Evaluation Report. This report summarizes the overall performance of each Resident in the areas of written and oral communication, leadership skills, group work contributions, and research ability.

b. Written and verbal feedback of overall performance from staff members is received at mid-term and upon completion of the program, as obtained during formal counseling sessions.

c. All candidates meeting above performance criteria will be eligible for graduation.

Information obtained from each student’s performance criteria will enable the program director and assistant program managers to assess overall weaknesses and strengths of the program to facilitate improvements in all instructional areas.

Curriculum Doctor of Science in PA Studies with Specialization in Orthopaedics (DScPA-CO)

TABLE OF CONTENTS

1. Introduction

a. Mission Statement

b. Vision Statement

c. Rationale for DScPA-CO Degree

d. Description of Titles and Responsibilities.

2. DScPA-CO Requirements and Opportunities

a. Education

b. Presentations

c. Research

d. Professional

e. Requirements for Successful Completion of the DScPA-CO

f. Supervision

g. Length of Residency

3. Overview and Organization of DScPA-CO Residency

a. Clinical Rotations

b. Didactic Subjects and Reading Assignments

c. Procedure Skills

d. Public Speaking

e. Research

4. Phases of the Residency

a. Orientation Month

b. Clinical and Didactic Phase One

c. Clinical and Didactic Phase Two

d. Commencement

5. Research Requirements

a. Purpose

b. Overview

c. Goals/Objectives

d. Required inclusions

e. Optional Objective

f. Faculty Advisor

g. Research Requirement Milestones

6. Curriculum Overview

7. Complete Curriculum

8. Performance Outcome Measures

1. Introduction.

a. Mission Statement. Our mission is to produce the best Orthopaedic PAs(PAs) in the world to serve Military Health System beneficiaries especially soldiers on the battlefield, effectively extend Orthopaedic surgeons to help recapture lost workload for the AMEDD and provide a professional development opportunity for PAs to improve recruiting and retention for the United States Army.

b. Vision Statement. Our Vision is to create the benchmark for post-graduate Orthopaedic PA education through the pursuit of academic and clinical excellence.

They will possess advanced operational and clinical training accomplished through two primary purposes. The first is to produce graduates with expertise in evidenced based Orthopaedic care for examining, diagnosing, and managing a variety of non-operative musculoskeletal injuries and conditions in an outpatient setting and on the battlefield.

The second is to ensure competency in research design, methods, analysis and critical review. Our graduate Orthopaedic trained PAs may also function as clinical scientists and will become future leaders and mentors by setting the example of scholarly excellence for PAs worldwide.

c. Rationale for DScPA-CO Degree.

(1) The Orthopaedic PA Residency provides Army PAs an opportunity to develop advanced competencies in both operative assistance and non-operative management of Orthopaedic conditions. This rigorous, comprehensive training will be conducted at one of three U.S. Army Medical Centers; Brooke AMC- Fort Sam Houston, TX, William Beaumont AMC- Fort Bliss, TX, or Madigan AMC- Fort Lewis, WA. Graduates will utilize these same skills and competencies to assist Orthopaedic surgeons in the operative treatment of injured and critically wounded soldiers on the battlefield or to stabilize operative and non-operative injuries for transport to higher echelons of care and rehabilitation. The experience gained during the residency in the acute management of traumatic injuries will significantly enhance the U.S. Army Orthopaedic PAs ability to successfully manage injured soldiers in a field or combat environment.

(2) Traditionally, those entering the PA profession do so as a graduate of an accredited residency with either a Bachelor of Science or Master’s degree. Individuals desiring doctoral level degrees had to pursue the traditional academic route of a Doctor of Philosophy (PhD). Those desiring post-professional education emphasizing clinical skills sought advanced standing Masters degrees, with only a few of which are residency based, academically intensive or specialized clinically.

(3) Our residency intends to distinguish the educational progression between the entry-level Master’s degree and the advanced clinical training gained in this proposed residency. No other residency-based residency requires individual research, and many do not have the clinical residency requirements that make our curriculum so strong.

This residency includes an expanded curriculum of 18 months to allow for more clinical education and hands on experience compared to the previous 12-month residency. Our emphasis on individual research and evidence based practice; in combination with our excellent clinical curriculum make our residency unique. Other residencies are not able to match our strengths in both areas. The DScPA-CO degree will further emphasize our focus on the continuous comprehensive study necessary to provide Gold Standard Orthopaedic care that the Army is known for. At this time, our residency will be the only residency in the country to offer the DScPA-CO degree for advanced clinical training in Orthopaedics.

d. Description of Titles and Responsibilities. In this document, members of the government faculty are described as follows:

(1) Medical Director, Clinical Orthopedics (CO) Residency (ABEM certified 62A9B/AAOS Certified 61M)

(2) Program Manager, U.S. Army DScPA-CO Residencies

(3) Chief Research Director (RD), CO Residency Program/Postgraduate training

(65DM1/M2)

(4) Program Director (PD), CO Residency Program (65DM1/M2)

(5) Assistant Program Director (APD) CO Residency Program/ Postgraduate training (65DM1/M2)

(6) Research Director (RD) Site Specific, CO Residency Program/ Postgraduate training (65DM1/M2)

(7) Academic Advisor/Preceptor, (62A or 65DM2)

(8) Staff/Preceptors

(9) CO Resident - Students

2. DScPA-CO Requirements and Opportunities.

a. Education.

(1) Attend and participate in clinics as scheduled during all rotations with staff Physicians to achieve all goals and objectives as set forth in Orthopaedic PA Residency curriculum.

(2) Experience one-on-one clinical education opportunities with orthopaedic surgeons and orthopaedic PA staff.

(3) Experience one-on-one clinical interaction with trauma surgeons, internists, pediatricians, radiologists and a variety of other physician specialists.

(4) Attend weekly blocks of instruction in the study of orthopaedic surgery and related topics. Orthopaedic surgery staff and Residents will cover the didactic material in the form of lectures and group discussions. Other educational resources include a medical reference library, audiovisual aids, computer-assisted data management systems and reference software.

(5) Attend Morning Report daily. Morning Report comprises case presentations in oral board format.

(6) Participate in opportunities such as research presentation at PA professional conferences when the opportunity arises and funding is available.

(7) Maximize all opportunities to enhance skills and experience gross anatomy as “surgical first assist” with orthopaedic surgeons in the operating room.

(8) Assist and perform multiple outpatient Orthopaedic clinic casting and minor surgical procedures.

b. Presentations.

(1) Defend research proposal to the Institutional Review Board.

(2) Prepare and present Grand Rounds Lecture when required.

(c) Prepare and present one Orthopaedic-related lecture to a primary care physician/ PA audience. The topic to be approved by the Residency Director/Manager.

c. Research.

(1) Each Resident will initiate or complete a research project related to Orthopaedics.

(2) The research project will be considered initiated when it is accepted by the IRB and data collection has begun. The research project will be considered complete when it is submitted to an indexed, peer-reviewed journal. (See Research Section for Details)

(3) All publications and related research associated with the Residency will be maintained by the Research Coordinator or the Director of Residencies of the Orthopaedic PA Residency Residencies, and will list the resident’s names and appropriate staff’s names.

(4) No presentation of research material will be made to any conference or local medical education groups without prior approval of the Program Director, Orthopaedic PA Residency, or his designee.

d. Professional.

(1) Maintain a current, valid National Commission on Certification of PAs (NCCPA) license.

(2) Keep credentials file current. (Maintained by Credentials Services Office)

(3) Provide appropriate and timely medical record documentation on all patients.

(4) Maintain current CPR-Provider certification.

e. Requirement for Successful Completion of the DScPA-CO.

(1) Obtain a minimum of 80% on all written examinations.

(2) Obtain a minimum of 80% on the midterm and final written cumulative multiple-choice examination.

(3) Successfully pass the midterm and final oral board examination. (During oral boards, Residents investigate a patient encounter from initial presentation until final disposition, verbally describing the process to orthopaedic surgeons and orthopaedic PA Staff as chosen).

(4) Initiate or complete a research project.

(5) Complete each individual requirement satisfactorily.

(6) Complete a lecture presentation to a Primary Care audience.

f. Supervision.

(1) The Residency Director/ Manager is the direct supervisor for each resident.

(2) The Director will ensure that each resident has successfully met all curriculum requirements leading to graduation.

(3) The director will also serve as the rater on the residents Officer Evaluation Report (OER).

g. Length of Residency. 18 Months (July to December)

3. Overview and Organization. For convenience and organization, the residency curriculum is divided into (4) major sections: Clinical Rotations, Procedure Skills, Didactic Subjects/Reading assignments, and Public speaking and Research. Each clinical rotation is scheduled for a specific time, will include reading assignments and in some cases, a procedure lab specific to that area of Orthopaedic practice. However, if unforeseen circumstances arise, adjustments will be made to the schedule. Prior to commencing any new rotation, the Residency Director/Manager explains the goals and objectives of the particular rotation. Finally, as with any educational residency, constant discussion, feedback, and analysis are expected during each rotation to promote continued growth and improvement of the residency.

a. Clinical Rotations. The most important objective of the Orthopaedic PA Residency is clinical competency. Specialty PA’s need to know what our job is, why we do it, and how to perform our duties to standard. Residents follow a comprehensive curriculum to establish a firm base of Orthopaedic Clinical competency. Direct patient care, discussions and hands on learning are examples of tools utilized to increase knowledge during this phase of the residency. During each clinical rotation, the residents interact and work with physicians in various areas of medical specialties that provide critical learning and skill sets.

b. Didactic Subjects and Reading Assignments. The initial (6) months of training for the Orthopaedic PA residents will be comprised of intensive reading assignments and lectures. Orthopaedic topics covered set the educational base for which the remainder of training will build upon. During each rotation, residents are assigned required reading from Fractures in Adults: 6th Edition, Rockwood and Green. This reference text and all related assignments and tests are updated whenever a new edition is released.

Attempts are made to correlate reading assignments with clinical rotations to enhance both the reading and rotational learning objectives. Residents also sit for several examinations during the curriculum, which serve to assess progress. Also during each rotation, residents are required to attend and participate in Grand Round lectures with Orthopaedic surgery residents. These lecture topics rotate over an (18) month period.

PAs are challenged with questions, leading to the development of effective and efficient clinical management of patients.

c. Procedure Skills. Orthopaedic PA residents gain skills in many outpatient procedures through direct, hands on patient care under the careful supervision of residency trained Orthopaedic PA’s, chief residents and staff surgeons. Emphasis during these training opportunities is on development of skills as well as the indications for and contraindications of the minor surgical procedure. Each Orthopaedic PA resident will receive demonstrations, discussions and hands-on training as detailed below:

(1) Demonstrate the following procedures:

(a) Orthopaedic casting and splinting

(b) Appropriate brace application

(c) Compartment pressure monitoring

(c) Ankle syndesmosis screw removal

(d) Rockwood screw removal

(e) Large joint injections/aspirations

(f) Steroid injections (subacromial, knee, ankle, SI joint, trigger-finger, etc.)

(h) Extensor tendon repair

(i) Nail bed repair

(j) Traction pin placement

(k) Metacarpal pin placement

(l) I &D of superficial abscess

(m) ACL graft preparation

(2) Demonstrate the ability to apply the following splints or casts:

(a) Alumafoam-finger Splint

(b) Posterior Splint of Ankle

(c) L&U Splint

(d) Short Leg Cast

(e) Long Leg Cast

(f) PTB Cast

(g) Hip Spica Cast

(h) Volar Wrist Splint

(i) Ulnar Gutter Splint

(j) Ulnar Gutter Cast

(k) Thumb Spica Cast

(l) Short Arm Cast

(j) Long Arm Cast

(k) Posterior Elbow Splint

(l) COBRA Cast/Clam Digger Cast

(m) Coaptation Splint

(n) Sugar Tong Splint

(3) Demonstrate the ability to perform the following suture techniques:

(a) Figure of Eight

(b) Subcuticular

(c) Simple Interrupted

(d) Horizontal Mattress

(f) Vertical Mattress

(g) Trauma Suture

(h) Instrument Tie

(i) Two Handed Surgeons Knot

(j) One Handed Surgeons Knot

(k) Arthroscopic Knot Tying

(l) Krakow (m)Brunnell

(4) Demonstrate the ability to perform the following procedures/injections:

(a) 1st MTPJ Joint Arthrocentesis

(b) CRPP Phalangeal Fracture

(c) CRPP Metacarpal Fracture

(d) Extensor Tendon Repair

(e) Finger Revision Amputation/Nail Bed Repair

(f) Ankle Arthrocentesis/Injection

(h) Knee Arthrocentesis/Injection

(i) Pre-Patellar Bursa

(j) Dorsal Wrist Ganglion Aspiration

(k) Elbow Arthrocentesis

(l) Acromioclavicular Injection (m)Trigger Finger Injection

(n) Carpal Tunnel Injection

(o) Medial Epicondyle Injection

(p) Olecranon Bursa Injection/Aspiration

(q) Lateral Epicondyle injection

(r) Compartment Pressure Lower Leg

(s) Compartment Pressure Upper Leg

(t) Compartment Pressure Forearm

(u) Hip Joint Injection

(v) Symphysis Pubis Injection

(w) Greater Trochanter Injection

(x) Pelvic Stabilization

(y) Femoral Traction Pin

(z) Bucks Traction

(aa) Minor Hardware removal

(3) Demonstrate the ability to perform the following nerve blocks used in the basic practice of Orthopaedics:

(a) Digital

(b) Metacarpal

(c) Median at Wrist

(d) Ulnar at Wrist

(f) Radial at Wrist

(g) Hematoma Block

(4) Demonstrate the ability to perform reduction of the following common joint dislocations and fractures:

(a) Tarso-Metatarsal Fracture

(b) Subtalar Dislocation

(c) Ankle Fracture/Dislocation

(d) Tibula/Fibula Fracture

(e) Knee Dislocation

(f) Hip Dislocation

(g) Pelvic Stabilization

(h) Phalangeal Joint Stabilization

(i) Phalangeal Fracture

(j) Metacarpal Fracture

(k) Carpal-Metacarpal Dislocation

(l) Distal Radius Fracture (m)Both Bone Forearm Fracture

(n) Supracondylar Fracture

(o) Humeral Shaft Fracture

(p) Shoulder Dislocation

(q) Elbow Dislocation

(r) Radial Head Dislocation

d. Public Speaking. The PA profession conducts multiple conferences in many different specialties each year. As the only Doctor of Science degree residency specializing in Orthopaedics, many opportunities to present lectures at these conferences will become available for our residency graduates. Each resident is required to present a lecture to a primary care audience during the last (6) months of the residency. This exercise serves multiple purposes. First, it prepares the resident for public speaking opportunities. It also serves to assess their skills as a speaker and potential as an educator. Lastly, it assists the resident in developing poise in front of an audience of their peers. The lecture should provide advanced Orthopaedic knowledge of an Orthopaedic subtopic to entry level Family Practitioners and PAs. Residents are expected to act as the subject matter expert and produce a 1-hour lecture/ presentation on a subject of their choosing.

e. Research. The PA Residents are actively involved in research projects during their (18) month curriculum. Each Resident initiates and completes a research project during the residency. The completed project’s manuscript will be submitted to an indexed, peer-reviewed journal for publication. In addition, Residents are expected to familiarize and support ongoing research within the PA Residency and the concurrent Orthopaedic Surgery Residency.

5. Phases of the Residency. The U.S. Army Orthopaedic PA Residency is divided into four overlapping phases with specific goals to be met during each phase. The Residency Director/Manager discusses the overall Residency goals/objectives with the resident as part of the orientation process. Then, the Residency Director or Residency Manager will discuss the goals/objectives of each new phase as it begins. The purpose of these goals/objectives is to provide residents with a chronological perspective of the Residency expectations throughout the year. These goals provide the residents with a framework from which to work. Occasionally, due to unforeseen circumstances, the Residency Director/Manager may modify the schedule.

a. Orientation Month (First Month).

(1) Introduction. Upon arrival to the assigned residency training facility, residents will begin in- processing and have adequate time to settle themselves and families into the area. During the first few weeks after arrival, residents will meet many staff and health professionals and tour different clinics and facilities. Specific orientation takes place with the Orthopaedic Department Physicians and Staff, as well as the Chief Residents as scheduled during the orientation rotation.

(2) Goals/Objectives of Orientation:

(a) Become oriented to assign Medical Center and surrounding area.

(b) Become oriented to the clinics and various staff.

(c) Become oriented to the Overall Orthopaedic PA Residency Curriculum/ Syllabus.

b. Clinical and Didactic Phase One (Months 2-7).

(1) Introduction:

(a) Residents spend this time embarking on rigorous reading requirements while working in various clinics within the Department of Orthopaedics and throughout the Medical Center. Residents will be involved in direct patient care, working directly with the ancillary staff, chief residents, Orthopaedic staff surgeons and a wide range of other physicians working in different specialties on assigned rotations. During this Phase, Orthopaedic PA residents will assume Orthopaedic First-Call duties under direct supervision of an Orthopaedic PA or a Chief Orthopaedic Surgery Resident. First- Call responsibilities for Orthopaedic PA residents during this phase should be limited to 5-6 times per month.

(b) Residents will also be allotted time to work on their research projects.

Realizing, that this is not a research-oriented course, but research is considered an important part of the clinical curricula and is weighted appropriately in the overall grade.

During these six months, Residents will experience a wide range of learning opportunities. Lectures from various specialists will help provide a well-rounded educational experience. The Orthopaedic PA Residency curriculum, practical exercises and data collection for research projects further challenge the residents during these few short months. This is a very busy, but valuable time for residents.

(2) Goals/Objectives:

(a) Become proficient in all “normal” clinic procedures.

(b) Become proficient in routine and specialized casting and splinting.

(c) Begin residency didactic curriculum.

(d) Attend Grand Rounds lectures, journal club meetings and be prepared to present a lecture if requested.

(e) Develop skills in radiograph, MRI and CT scan interpretations as they relate to the management of orthopaedic patients.

(f) Become proficient with anatomical terms as they relate to musculoskeletal anatomy, and be able to discuss locations, components, and functions.

(g) Research proposal must be completed by end of month (2), or integration into a research project from the previous class.

(h) Present research proposal before the hospital IRB and begin data collection by the beginning of month (6)

(i) Research project will focus on orthopaedic issues or conditions and provide an update or addition to the overall professional literature reviewed.

(j) Assist with data collection for other ongoing Department of Orthopaedics studies.

(k) Become familiar with the pathogenesis, signs/symptoms and management of common orthopaedic conditions.

(l) Provide the proper management for a patient with a specific diagnosis of a traumatic orthopaedic condition/injury.

(m)Be able to identify orthopaedic emergencies.

(n) Score above 80% on all periodic performance evaluations.

c. Clinical and Didactic Phase Two (Months 8-17).

(1) Introduction. During this Phase of training Residents will receive increased clinical responsibilities. Reading requirements will continue throughout the residency and will be tailored as they relate to each unique patient encounters. Rotations in the subspecialty areas of pediatrics, spine, foot &ankle, hand, sports, trauma, total joint and tumor as well as physical/occupational therapy, and neurology will be completed during this Phase. Residents will gain the necessary skills and confidence to begin orthopaedic first-call responsibilities with staff surgeon or senior resident backup.

(2) Goals/Objectives:

(a) Given a patient and the necessary equipment, use proper techniques for patient interviewing while correctly recording a medical history. Perform a complete physical examination. Correctly record the information obtained, providing a diagnosis, and treatment plan.

(b) Become proficient in orthopaedic clinic procedures:

(1) compartment pressure monitoring

(2) hardware removal

(3) nail bed repairs

(4) extensor tendon repairs

(5) percutaneous pinning of metacarpal fractures

(6) common joint Arthrocentesis

(7) appropriate use and application of braces

(8) laceration repair and wound management

(c) Continue data collection for research project, final manuscripts on completed projects will be due by the end of Month 17.

(d) Read required literature for each rotation and prepare for final examination and oral board.

(e) Become familiar and proficient in operating room functions and procedures.

(f) Become a proficient first assistant for an orthopaedic surgeon.

(g) Score above 80% on all periodic performance evaluations.

d. Commencement (Month 18).

(1) Introduction. Residents will graduate, begin out-processing and prepare for their next duty assignment as an Orthopaedic PA – Certified.

(2) Goals/Objectives.

(a) Complete final exam and residency evaluation.

(b) Pass oral board.

(c) Out-process and prepare for next duty station.

(e) Graduate.

5. Research Requirements.

a. Purpose.

(1) Research is the foundation and progressive lifeline of any medical profession.

We recognize the importance of training residents in research methodology and critical literature review. The focus of this degree is primarily a clinical degree, not a research-centric degree. However, the ability to analyze and critically assess the medical literature becomes even more important after completing formal residency training, as medical journals and other periodicals becomes the cornerstone of most PAs continuing medical education (CME).

(2) In an era of dwindling resources and budget constraints, military health care providers are continuously compelled to provide efficient and effective care. To meet these demands the Orthopaedic PA Residency has been shifting from the long standing “expert based” to “evidenced based” practice. The advent of the Evidence-Based Medicine (EBM) movement has furthered these endeavors, and provides a logical model for further investigation and intellectual growth within our chosen specialty.

(3) Clinicians must continue to question the validity of traditional practices and procedures, particularly those that have not met scientific scrutiny. In addition to the importance of self-education, research methodology is taught in Orthopaedic residency programs in the hope of fostering continued interest in scientific inquiry among Orthopaedic practitioners. Such inquiry has served both to establish the unique body of knowledge that comprises “expertise” in the field of orthopaedics, and has simultaneously pushed-back the “walls of dogma” that have historically surrounded so much of the treatment of acutely ill and injured individuals.

(4) Another purpose of research is to investigate common practices and share the results with colleagues and other health care providers. To accomplish this each resident will initiate or complete an approved research study and submit the findings to an indexed, peer-reviewed journal. The research project requirement will positively contribute to the body of knowledge shared by providers throughout the eclectic field of orthopaedics, and the PA profession in particular.

b. Overview.

(1) The resident will be required to develop a research proposal and answer a specific research question. This will be accomplished as an individual project.

(2) Residents will create an IRB approved protocol, execute the protocol, and submit the results for publication.

c. Goals/Objectives.

(1) Goals:

(a) Describe the fundamental techniques of critically analyzing biomedical research, and demonstrate the ability to do so in a public forum.

(b) Describe the basic methods of hypothesis development and testing.

(c) Describe various types of study design and methodology.

(d) Be aware of the various methods of obtaining consent for biomedical research.

(f) Describe basic statistical methods and their respective applications.

(g) Demonstrate and reinforce a strong ethical grounding for the conduct of clinical research.

(h) Describe the skills to develop a manuscript that is acceptable for publication in a peer-reviewed journal.

(i) Describe the need for grants and funding of research, and develop a rudimentary understanding of how to pursue research funding both effectively and ethically.

(j) Foster an understanding and potential interest in academic Orthopaedic as a career.

(1) Objectives:

(a) Participate in the didactic research course, successfully completing the outlined assignments and the post-test.

(b) Attend and participate actively in Journal Club as schedule permits.

(c) Complete the assignments for the EBM Reading Module.

(d) Complete other required research reading as outlined in the reading guide.

(e) In conjunction with the Residency Director, develop and successfully execute a plan for completion of the “Resident Scholarly Activity Requirement.” This requirement has been crafted in a manner that allows tailoring and selection of activities based upon personal preference, interests and career goals, and integrates both individual projects as well as didactic components of the research curriculum. In order to track progress and scholarly output, we have adopted a quantitative “point system” comprised of the various didactic programs and acceptable forms of scholarly activity.

Points will be adjudicated and awarded by the Residency Director. Residents will be required to accumulate a total of 17 points in order to meet graduate requirements, from the following menu:

12 points (mandatory) – Successful design, execution and completion of program director pre-approved case-control, prospective observational, clinical trial or systematic review project (the traditional “soup-to-nuts” research project).

6 points – Successful completion of program director pre-approved “Evidence Based Orthopaedic Review” topic in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) format, and submission to a peer-reviewed MEDLINE-indexed medical journal.

4 points – Successful development, completion, submission and selection for presentation of program director pre-approved “Innovations in Orthopaedic Education” Project in SAEM submission format.

3 points – Successful completion program director pre-approved case report / case series with detailed review of the literature, and submission to a peer-reviewed MEDLINE-indexed medical journal.

3 points – Successful preparation and execution of a program director with cases selected based upon guidelines used by the DScPA-EM program from pre-approved and SAEM/CORD-EM selected CPC case presentations.

2 points – Successful completion of Winter Research Symposium (metric = post-test and mock protocol).

1 point – Successful preparation, selection, presentation and peer-reviewed, MEDLINE-indexed journal publication of a program director pre-approved scholarly abstract (presented at a national medical meeting).

1 to 3 points – Successful preparation, selection, and peer-reviewed, MEDLINE-indexed journal publication of a program director pre-approved scholarly project manuscript.

1 point – Successful preparation and execution of a program director pre-approved lecture (usually presented during Basic Skills Course).

1 point – one year credit for Journal club participation (metric = post-quiz).

1 point – successful completion of reading program.

(f) In all cases, scholarly projects must include the following elements:

Problem identification and/or hypothesis formulation.

A formal phase of information gathering or data collection.

Critical analysis of the data or information obtained.

A formal statement or report of interpretation of results and conclusion.

Submit to the program a publishable-quality research report summarizing the project. The report must conform to research policy to include on-time submission.

(g) In addition to these required objectives, residents are strongly encouraged to consider the optional objective of submitting a paper to a peer-reviewed journal.

(h) Residents must select a faculty advisor for their research project. The faculty advisor may be the resident’s faculty mentor, program manager, program director or another faculty member. With permission of the program director, a faculty member outside of orthopaedic may be selected.

g. Research Requirement Milestones.

(1) Specific milestones will be established and residents will be expected to meet them as they progress towards their final project. These milestones are minimums;

residents should strive to beat these suspense dates well in advance. These milestones are as followed:

(a) Upon selection to Orthopaedic Program the student must register and complete the online training for biomedical research at www.citiprogram.org.

(b) Research question prepared and approved by Residency Director by resident’s report date.

(c) Rough draft of research proposal turned into Residency Director by end of July of the first training year. Revision will be turned in by mid-August, and final draft turned into IRB 30 days prior to October IRB meeting. Upon request by the IRB for revision of the research proposal, the student will ensure the final draft will be turned in 30 days prior to the January IRB meeting.

http://www.citiprogram.org/

(d) Progress of the research will be evaluated by Residency Director quarterly, at a minimum.

(e) All data collection will be completed by end of month August of final training year.

(f) Rough draft must be turned in to Program Manger by mid-September, and revisions turned in by October 1st. Final draft must be completed by end of month October.

(g) The final research paper will be turned into IRB for review and approval for publication by end of month October in the final training year.

(h) The Student will defend his research project by 1st week of December.

The defense board will be made up of the Medical Director, Residency Director, and two additional members, which can be individual site hospital staff or Orthopaedic staff from other sites.

(2) Residents not meeting these milestones will be found not in compliance with program requirements.

(3) With the input of the research directors, it is crucial that each resident construct a feasible “roadmap” early in the course of their training, which they will use to fulfill their graduation requirements. Close coordination with their faculty research advisor and the program director is important. All expectations of participation should be coordinated in advance.

(4) Identify the roles of all participants. In general, only one resident can claim to be the principal investigator on a study. Large studies with multiple components may be able to support multiple residents, but this must be approved in advance and will primarily be limited to extra scholarly activity by residents in on going staff research projects.

(5) Identify authorship for future papers submitted to journals. The general rules of journal authorship dictate that the first author is the individual most responsible for producing the manuscript (as opposed to the principal investigator, who takes lead in running the study). Often these are the same individual. The preceding discussion applies to articles submitted for publication. Take note that the resident is wholly responsible for writing up his or her results of the research project to meet graduation requirements.

(6) The Director, Orthopaedic Residencies is responsible for tracking the progress of all resident research and providing regular updates to the program leadership.

(7) The Program Director, Program Manager, Research Director and Medical Director will convene an informal board, quarterly, in conjunction with individual counseling, to review all ongoing projects. The faculty members will give recommendations for the residents’ research requirement.

(8) Graduating residents will be required to submit their final report to the IRB prior to receiving credit for the project and being cleared for graduation. It is the principle investigator’s (resident) responsibility to properly close the protocol with the IRB when departing the institution.

(9) All academic and related papers, abstracts, publications, and academic presentations made outside the program will be submitted to the Research Director for review and approval, and if necessary, to the chain of command for review and approval.

6. Curriculum Overview.

a. Introduction. The medical community nationwide recognize the Army Medical Centers. Many experienced physicians, from all specialties, work together to provide the best education for all medical Residents, Residents and allied health Residents.

The residency focus is to make the US Army Orthopaedic PA Residency the leading institution in Orthopaedic PA training and research.

b. Goals and Objectives. (See Curriculum Course Syllabus for specific goals and objectives)

(1) Didactic: Provide post-graduate instruction on:

(a) Orthopaedic care to people of all age groups

(b) Public speaking forums

(c) Research design and statistical analysis

(2) Evidence-based practice

(a) Increase “current” knowledge of professional literature through publishing pertinent research.

(b) Provide weekly Grand Rounds lectures covering all aspects of orthopaedic medicine practice.

(c) Provide monthly advanced trauma life support procedure lab focusing on resuscitative techniques

(3) Practical.

(a) Demonstrate evaluation and management techniques for all patients presenting to the orthopaedic department focusing on fundamentals of orthopaedic practice and treatment.

(b) Utilize radiologic imaging to evaluate a variety of conditions.

(c) Provide an overall competency.

(d) Contribute to ongoing research projects at residency sites.

(4) Miscellaneous. Assist with the administration of the PA Residency, specifically with the management of scheduling, continuous quality improvement of residency rotations, and other Residency related activities as required.

c. Plan.

(1) Didactic:

(a) The Orthopaedic Medicine-PA Residency includes a comprehensive curriculum with weekly classes conducted on a stimulating variety of topics. The classes are designed to inspire critical thinking, and where applicable, to incite discussion of current practice and theory with scientific evidence.

(b) Miscellaneous journal club, research or other meetings, journal review club, and/or in-services also aid in increasing didactic knowledge.

(2) Practical:

(a) The Residents work side by side with physicians in different specialties.

Patient evaluation, differential diagnosis, analysis through application of a variety of testing methods, interpretation of test results and treatment options are discussed.

(b) For details in research administration, see Research section.

d. Evaluation of Performance.

(1) Didactic. The Resident achieves the goals and objectives of the didactic portion by:

(a) Completing the reading and other assignments for each specific rotation in the curriculum and actively participating in classroom discussions.

(b) Attending journal clubs, lecture series seminars, research meetings, in-services and related activities.

(c) Achieving a minimum of 80% on tests based on reading assignments, a midterm and a final test.

(2) Practical Portion. The Resident achieves the goals and objectives of the practical portion by:

(a) Completion of each clinical rotation in accordance with the expectations of their supervising physician.

(b) Completion of procedure practice labs in accordance with the expectations of the supervising faculty.

(c) For Residency grading criteria, see Performance Outcome Measures.

(d) For evaluation of research projects, see Performance Outcome Measures.

Complete Curriculum for DScPA-CO Residency

Didactic Portion

OPA 101 Biomechanics of Fractures and Fixation OPA 102 Classifications of Fractures OPA 103 The Multiply Injured Patient with Musculoskeletal Injuries OPA 104 Anesthetic Care of the Trauma Patient OPA 105 Nonoperative Fracture Treatments OPA 106 Principles of Internal Fixation OPA 107 Principles of External Fixation OPA 108 Bone and Joint Healing OPA 109 Tendon, Ligament, Meniscus, and Skeletal Muscle Healing OPA 110 Open Fractures, Vascular Injuries and Compartment Syndromes OPA 112 Penetrating Trauma OPA 114 Bone and Soft Tissue Reconstruction OPA 115 War Wounds, Limb Salvage, and Traumatic Amputations OPA 116 Complications of Injury to the Musculoskeletal System OPA 117 Pathologic and Periprosthetic Fractures OPA 118 Fractures and Dislocations of the Hand OPA 119 Fractures and Dislocations of the Wrist OPA 120 Fractures of the Distal Radius OPA 121 Fractures of the Shafts of the Radius and Ulna OPA 122 Fractures and Dislocations of the Elbow and Distal Humerus OPA 128 Subluxations and Dislocations About the Glenohumeral Joint OPA 129 Injuries to the Acromioclavicular and Sternoclavicular Joints OPA 130 Fractures of the Shaft of the Humerus OPA 131 Fractures of the Proximal Humerus OPA 132 Fractures of the Clavicle OPA 133 Fractures of the Scapula OPA 135 Fractures of the Pelvic Ring OPA 136 Fractures of the Acetabulum OPA 138 Hip Dislocations and Fractures of the Head and Neck of the Femur OPA 139 Intertrochanteric Fractures OPA 140 Subtrochanteric Fractures OPA 141 Fractures of the Shaft of the Femur OPA 142 Fractures of the Proximal Tibia and Fibula OPA 143 Fractures of the Patella OPA 145 Injuries of the Knee OPA 146 Fractures of the Tibia and Fibula OPA 147 Ankle Fractures OPA 148 Fractures of the Talus OPA 149 Fractures and Dislocations of the Calcaneous OPA 150 Fractures and Dislocations of the Midfoot and Forefoot

OPA 200 General Orthopaedics OPA 201 Articular Cartilage Injuries of the Knee OPA 202 Anterior Knee Pain and Patellofemoral Joint Instability OPA 203 Genetics I and II, Developmental Dysplasia of the Hip (DDH), Legg-Calve- Perthes Disease and Slipped Capital Femoral Epiphysis (SCFE) OPA 204 Orthopaedic Surgery in the Immunocompromised Patient OPA 205 Osteoarthritis OPA 206 Benign Bone Tumors OPA 207 Prioritization and Management of the Polytrauma Patient OPA 208 Ligamentous Injuries of the Foot and Ankle OPA 209 Knee Ligament Injuries, Epidemiology, Mechanism, Diagnosis, and Natural History OPA 210 Knee Meniscal Injuries OPA 211 Diagnosis and Management of Musculoskeletal Infection OPA 212 Overview of Arthritis OPA 213 Pathophysiology of Bone Tumors OPA 215 Orthopaedic Sports Medicine OPA 216 Spinal Pain

Practical Clinical Rotations

OPA 300 Orthopaedic Procedure Requirements OPA 301 Foot and Ankle OPA 302 Spine OPA 303 Pediatrics OPA 304 Total Joint Replacement OPA 305 Hand OPA 306 Sports Medicine OPA 307 Trauma OPA 308 Bone Tumors OPA 310 Neurology OPA 311 Elective

(OPA 101) Biomechanics of Fractures and Fixation

1. DESCRIPTION: This section will provide the Orthopaedic PA Resident with a basic Discussing of the biomechanics of fractures, the biomechanics of implants used to fix fractures, and problems associated with implants and specific fracture patterns.

2. GOALS:

a. Describe the basic concepts of the biomechanics of fractures and fracture fixation

b. Describe the biomechanics of intact and healing bone

c. Describe the biomechanics of bone fracture

d. Describe the biomechanics of fracture implants

e. Describe the mechanical problems associated with specific fixation devices

f. Describe problems unique to fractures in specific locations

3. OBJECTIVES:

a. Describe the basic loads that act upon fractures

b. Describe the basic forces that act upon bones

c. Describe the structural properties of a construct

d. Describe implant structural properties of elastic, plastic range, and fatigue

e. Describe the concept of an implant stress concentrator

f. Describe the property of viscoelasticity

g. Describe the structure and make up of bone

h. Describe the factors that affect the strength of bone and a healing fracture

i. Describe that bone compensates for the stiffness of the implant and the final outcome of the healing fracture

j. Describe where bone is weakest and where it is strongest

k. Describe the affect aging has on bone

l. Describe the function of commonly used fixation devices

1) Cerclage wire

2) Screws

3) Plates

4) Intramedullary rods

5) Pins

6) Wire

m. Describe the problems associated with common fixation devices

1) Cerclage wire / pin breakage

2) Sheared screw, screw pullout, breakage

3) Plate breakage / deformation / failure

4) Fully threaded lag screw

5) IM rod insertion, locking screw breakage, wrong sized IM nail

6) Loosening of external fixator pins, pin tract infections

n. Describe problems unique to fractures in specific locations

1) Proximal femur

2) Metaphyseal region of the knee

3) Pelvis

4) Spine

4. IMPLEMENTATION:

a. Clinical rotations – The OPA Resident will be required to work in the area of his or her clinical rotation. Each Resident is to aggressively seek procedures during clinical shifts.

b. Reading assignments - Fractures in Adults, Rockwood & Green, chap. 1:

Biomechanics of Fractures and Fixation. Chapters 1-13 and 1-14, pages 116 through 140 in Fitzgerald’s Orthopaedics also cover this topic. Selected journal articles will be given to each OPA Resident to compliment the objectives listed.

c. Procedure laboratory – Monthly procedure labs will be conducted emphasizing required skills.

d. Radiology readings- Emphasis on radiological diagnosis of fractures, performed daily under surgeon supervision.

e. Saw bone training- Emphasis on surgical techniques to include intramedullary nailing and external fixation, quarterly and supervised by surgeons.

f. Operative training- Emphasis on first assist for treatment of open fractures, compartment syndrome, vascular injuries and wound closure techniques, variable and dependent on schedule.

g. On call training- Emphasis on history taking, physical examination, utilization of diagnostic tools, and pre-surgical treatment of open fractures, compartment syndrome, and vascular injuries, varies but generally on call every 3-4 days.

h. Cast room training- emphasis on fracture diagnosis and treatment, variable and dependent on schedule.

i. Morning report.

j. Grand Rounds lectures – Grand Rounds lectures – Weekly lectures will be attended. These lectures include over 11 hours on various Orthopaedic topics.

5. RESOURCES AND FACILITIES: Each OPA Resident will be provided all texts required to complete the goals and objectives as outlined in the curriculum. Rotation shifts will be conducted at the MTF or local civilian facility. Grand Round lectures will be held in the Orthopaedic Clinic Conference room, or other location as necessary. The Procedures lab will be held at designated areas at each MTF. The Medical library at each MTF is available 24 hours a day for research or study requirements.

6. DUTIES AND RESPONSIBILITIES OF THE ORTHOPAEDIC PA RESIDENT: The preceptor in the Orthopaedic Department will coordinate the duty hours during the rotation. Duty uniform will be either Class B or ACU’s, and hospital scrubs during clinical shifts or appropriate civilian attire in local civilian hospitals. Attendance at Grand Round lectures and the monthly procedure laboratory is mandatory. Direct supervision will be present and the goal is to increase ability to manage multiple patients.

7. ORTHOPAEDIC PA SUPERVISION, EVALUATION, AND FEEDBACK: The…