The University of British Columbia s7

T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A

Medical Oncology Rotation Goals & Objectives for Urology residents

Preamble: General Objectives

During a 1 block (4 week) rotation of Medical Oncology during PGY1 & PGY2 the urology resident will participate in the care of patients with a variety of malignancies. They will work with other physicians, surgeons, nurses and allied health personnel with special knowledge of oncology. VGH is the main teaching site for the five years of residency so the VGH rotations are central to working and learning at VGH. Secondary objectives include developing an understanding of VGH surgical services as well as meeting and developing personal knowledge of VGH staff to allow for easy communication and optimal patient-centered care in the future. The urology resident is expected to fully participate in the daily functioning of the Medical Oncology service. The following is an outline of general objectives for the rotation.

Locations:

BC Cancer Agency is a part of the PHSA and has a three part mission: 1) reduce the incidence of cancer, 2) reduce the mortality rate of people with cancer, and 3) improve the quality of life of people living with cancer. The Agency operates six regional centers (Abbotsford, Kelowna, Prince George, Surrey, Vancouver and Victoria) as well as the BC Cancer Agency Research Center (Vancouver, Victoria). The majority of BC chemotherapy services is administered by BCCA as is all of the radiotherapy services. Urology residents will gain Medical Oncology experiences at the Vancouver

Medical Oncology Goals and Objectives

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) location, across from VGH, via ambulatory clinics, inpatient ward management and on-call services.

Vancouver General Hospital is the largest Hospital in British Columbia and second largest in Canada. It houses more than a thousand beds spread across a diverse spectrum of clinical subspecialty areas. More than 40% of all referrals to VGH come from outside the Vancouver region as this site offers super specialized intensive care for the sickest patients in the Province. There are 21 operating rooms generating 23,000 outpatient and inpatient surgical cases per year, 40 outpatient clinics with almost 300,000 clinic visits per year and an Emergency Department which sees almost 95,000 patients visits annually.

VGH is also closely affiliated with the UBC Faculty of Medicine and houses the administrative offices in the Diamond Health Center Building, as well as represents the primary teaching site of the undergraduate and postgraduate training programs in the Faculty.

Because of the combination of high volume, specialized care within a highly academic and educational milieu, VGH is also at the crux of world class research and is in close proximity to leading research centers including the: Center for Clinical Epidemiology and Evaluation, Center for Hip Health and Mobility, Center for Heart and Lung Health, Immunity and Infection Research Center, International Collaboration on Repair Discoveries, Ovarian Cancer Research and the Vancouver Prostate Center. Over 1500 research personnel work in these research networks from basic science, to applied technology to preclinical and clinical trials.

Urology Competencies

Medical Expert:

The resident will learn skills to enable them to perform consultations utilizing available elements from patient history, physical examination, imaging and lab/special testing and adjunctive history from other health professionals. The component skills include but are not limited to: - Performing an appropriate focused history and physical exam of the oncology patient - Gather adjunctive data relevant to the presentation of the oncology patient, including medical imaging and reports, lab data, and special test results and reports as well as consultation reports from other health providers. - Synthesize gathered data and formulate differential diagnoses - Plan further diagnostic strategies to refine the diagnosis as required with sensitivity to patient concerns, cost and a rationale use of medical testing - Plan therapeutic strategies based on the oncologic diagnoses with sensitivity to patient concerns, and cost - Counsel patients and their families empathically and an evidence couched approach, respecting their cultural values and ethics - Understand the ethical, legal and cultural ramifications of oncologic diagnoses and their potential treatments - Formulate a follow up strategy to appropriately assess the therapeutic plan’s effectiveness and revise as required

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) - In all aspects, deliver written and verbal communication to attending or associated faculty or health care providers which is logical, direct and informative. - Formulate a plan for the safe and effective discharge of patients from clinic/ward back to their referring physician or primary care provider. - Actively contribute to continuous quality improvement of health care quality and safety

The primary objectives for urology residents in Medical Oncology rotations are outlined below: - The urology resident should develop familiarity with and competence in the diagnosis and management of patients with common neoplasms. - The urology resident should become familiar with the mechanism of action and side effects of common systemic therapies. - The urology resident should understand the principles of palliation and symptom control in the oncology patient. - Eliciting a history (including risk factors and family history) that is relevant to oncology - Performing a physical exam that is thorough but focused and pertinent to the presenting problem - Outpatient evaluation of patients presenting with elevated PSA, hematuria, testicular mass, generalized weight loss, ‘incidentaloma’ on abdominal CT scan, and ‘cancer of unknown primary’ -The diagnosis and management of emergencies such as superior vena cava syndrome, spinal cord compression, and metabolic emergencies (hypercalcemia, tumour lysis syndrome and SIADH) -The management of acute side-effects of treatment (with special emphasis on the management of nausea, vomiting and febrile neutropenia) - The principles of the palliative management of symptoms in the oncology patient such as pain control, shortness of breath, constipation, and bowel obstruction, brain metastases, pleural effusions, malignant ascites, bone metastases and biliary obstruction - Ethical, legal and philosophical considerations (including end of life care) - Including consent, power of attorney and alternate decision-makers. - Understand how decisions are made regarding end of life care. - The urology resident will focus his/her studying on material to be covered in the Royal College Principles of Surgery Exam (refer to G & O for Surgical Foundations curriculum)

Communicator:

The resident will develop and demonstrate skills Medical Oncologists use to effectively facilitate the doctor-patient and doctor-patient family relationship and the dynamic changes that occur before, during and after the medical encounter. These include but are not limited to: - Recognizing communication skills to be fundamental to delivery good care - Establishing trust, respect, honesty and empathy - Respect patient confidentiality, privacy and autonomy - Listen effectively - Recognize and be sensitive to nonverbal cues - Facilitate a structured clinical encounter effectively - Appreciate the impact of cancer on patients and their families.

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) The resident will further develop and demonstrate communication skills exemplified by: - Delivering information in a logical, direct and informative manner that is patient centered and encourages discussion - Communicate bad news to patients empathically - Respect patient diversity including race, sexual orientation, gender, religion and culture - Engage patients in shared decision making - Understand and engage patients and their families in the informed consent process - Address challenging communication issues effectively such as the angry, anxious, confused patient for example - Able to address challenging encounters including delivering ‘bad news’ - Generate and maintain clear, concise and informative documentation for recordkeeping and for communication with other health care providers - Present oral reports to peers, supervisors, other faculty or associated consultants / health care professionals in a clear and concise manner - Share health care information and plans with patients and their families

Collaborator:

The resident will develop and demonstrate skills Medical Oncologists use to work effectively within a health care team to achieve optimal patient care. These include but are not limited to: - Understand and communicate the Medical Oncologists role to patients, and other health care providers - Recognize and respect the diversity of roles, responsibilities and competencies of other professionals on the team - Work with other team members to plan, provide and integrate care for patients - Participate in interprofessional rounds / meetings - Demonstrate a respectful attitude towards other colleagues - Work with others to prevent and resolve conflict - Demonstrate safe handover of care

Leader:

The resident will develop and demonstrate skills Medical Oncologists use to make decisions about allocating resources, and contributing to the effectiveness of the health care system. These include but are not limited to:

- Work collaboratively with others in the organization - Participate in quality improvement initiatives - Describe principles of health care financing including physician remuneration, budgeting and organizational funding - Manage time and priorities appropriately to balance patient care, education and personal life - Demonstrate knowledge of issues related to running an office including staffing, billing and

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) maintaining patient records - Utilize information technology appropriately - Understand resource restrictions and allocate Medical Oncology resources in a rational and cost effective manner - Understand triaging patients on a waitlist - Demonstrate knowledge of resources available in the community to assist individuals with cancer. - Participate in meetings / rounds and provide leadership when appropriate - Understand and begin to implement the science of quality improvement to delivery of patient care - Analyze patient safety incidents to enhance systems of care - Demonstrate leadership in professional practice - Using case-based teaching, the resident will receive explicit instruction on prioritizing patients waiting for assessment and treatment.

Advocate:

The resident will develop and demonstrate skills to influence and advance the health and well being of individual patients, communities and populations. These skills include but are not limited to: - Identifying the health needs of individual, groups and populations of Cancer patients - Identify opportunities for health advocacy, health promotion and disease prevention - Identify determinants of health of populations including barriers - Identify vulnerable populations - Describe an approach to health promotion on an individual, community, and population policy level - Understand the dynamism that can occur between health advocacy and manager roles - Understand the role of the special interests groups affiliated with Cancer in Canada in advocating on behalf of Cancer patients.

Scholar:

The resident will develop and demonstrate skills Medical Oncologists use to achieve a lifelong commitment to reflective learning as well as the creation, dissemination and translation of medical knowledge. These include, but are not limited to: - Describing principles of maintenance of competence - Describing a personal knowledge management system - Participate in scholarly activities for the purpose of improving patient care (QA, lab work, case reports, clinical trials, etc) - Access and integrate new medical evidence into practice - Demonstrate principles of critical appraisal - Deliver effective presentations to patients, peers and other health professionals in evidence based manner - Ensure patient safety is maintained when learners are involved

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) - Demonstrate an understanding of the fundamentals of the basic sciences related to Medical Oncology. - Demonstrate an understanding of the fundamentals of critical analysis of the scientific literature in Medical Oncology commensurate with his/her level of training. - Demonstrate and ability to teach Medical Oncology to students and allied health professionals commensurate with his/her level of training.

Professional:

The resident will develop and demonstrate skills Medical Oncologists demonstrate in the establishment of ethical practice, profession-led regulation, and high personal standards of behavior. These include but are not limited to: - Exhibiting honesty, integrity, commitment, compassion, respect and altruism - Demonstrate adherence to best practices - Demonstrate meticulous documentation practices - Recognize and manage ethical issues in practice - Recognize and manage conflicts of interest in practice - Maintain appropriate boundaries with patients and their families - Understand and fulfil the regulatory and legal obligations required of current practice - Balance professional and personal life commitments appropriately - Demonstrate a commitment to patient safety and quality improvement - Demonstrate the ability to recognize and respond to societal expectations in health care - Exhibit professional behaviours in the use of technology-enabled communication - Demonstrate a commitment to physician health and well being to foster optimal patient care

Teaching Method

Medical Expert:

These competencies will be taught and assessed in the following ways:

1. Attending Medical Oncologists will be knowledgeable of the rotation goals and objectives and will be motivated to ensure each resident has sufficient exposure to clinical material. 2. High volume of consultations in a very busy Medical Oncology Service where residents will be the initial contact. 3. Bedside review of histories, physical signs, diagnostic testing including radiology with the attending Medical Oncologists 4. Careful review of resident documentation (dictated consults, OR reports and discharge summaries) to teach and evaluate medical expert competencies 5. Attendance at hospital based rounds (including weekly Medical Oncology noon rounds, noon rounds, as well as specific team focused didactic and ward rounds). 6. The teaching of procedural skills through supervision by a more senior member of the team.

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) 7. The availability of core reference material such as ‘The Basic Science of Oncology’, Tannock and Hill, 3rd edition; ‘Cancer Principles and Practice of Oncology’, Devita, Hellmon, Rosenberg, 5th edition, as well the web-based BC Cancer Agency Care Provider Information System and the Intranet BC Cancer Agency Systemic Therapy file. 8. Written ITER at the end of each block 9. Face-to-face feedback (in real time) throughout the rotation and at the end of the block.

Communicator :

These competencies will be taught and evaluated in the following ways:

1. During direct patient care, the residents will have the opportunity to speak and assess patients in the presence of the attending Medical Oncologists. Issues related to communication will be explicitly discussed and developed with the attending at an appropriate time. 2. Residents counselling and gathering of, and review of informed consent from patients will be directly observed and assessed to be fed back to the resident face to face with attending staff. 3. Resident delivery of status updates, bad news, or general communication with patients and their families will be assessed by faculty in realtime and fed back to the residents face to face. 4. Nursing evaluation of the junior residents’ communication skills will be done at the end of each block. 5. Respect patient privacy and confidentiality and be knowledgeable of the Vancouver Coastal Health Authority and UBC policy on patient confidentiality. 6. All written reports (consults, procedure reports, discharge summaries) will be reviewed by the attendings and feedback given. 7. During direct patient care, the residents will have multiple opportunities to assess and speak to patients in the presence of the Medical Oncologists. Issues related to communication will be explicitly discussed and developed with the attending at an appropriate time.

Collaborator:

1. The resident’s understanding of the roles and responsibilities of other health care professionals that interact with patients and families on the Medical Oncology Service will be assessed by attending staff. These other health care providers include family practitioners, medical and surgical specialists, community nurses, unit clerks, respiratory therapists, and laboratory and radiology technicians. 2. Understand inter-professional team function and demonstrate that they can work with others to minimize team conflict and optimize patient-centered care. 3. Direct observation of handover of care from one resident to another during periods of transition of care including: evening on-call, daytime on-call, daytime attending service, to another resident/fellow/faculty member, transfer of care to another service, transfer of care to another

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) facility, discharge planning, discharge summaries, communication with primary care provider or other responsible health care provider regarding pending or past discharge of patient.

Leader:

1. The resident’s ability to understand Health care expenditures and have a practical knowledge of cost-appropriate care for common emergency conditions; assessed by attending Medical Oncology staff. 2. Understand and utilize appropriate technology for interprofessional communication on a day to day basis with peers, faculty and other health care providers. 3. Participate in morning rounds, evening rounds, interdisciplinary rounds as a basis for gaining leadership insight and management skills. 4. Using case-based teaching, the resident will receive explicit instruction on aspects of medical practice, including; - Maintaining job satisfaction among team members - Maintaining medical records - Use of electronic medical records 5. Using case-based teaching, the resident will receive explicit instruction on the cost effective use of diagnostic tests 6. Using case-based teaching, the resident will receive explicit instruction on prioritizing patients waiting for assessment and treatment.

Advocate:

1. Identify the unique populations served by this hospital and Health Authority and the determinants and barriers to health while interacting with them during ER, inpatient and perioperative periods. 2. Able to advocate health promotion and disease prevention to patients at appropriate moments during an emergency consultation 3. The resident’s ability to understand availability of community support groups and patient advocacy groups for common medical and surgical conditions; assessed by attending Medical Oncology staff. 4. The resident’s ability to determine patients at risk for non-compliance and patients with barriers to access of care and be able to address these issues constructively; assessed by attending Medical Oncology Staff. 5. Identify where Special Authority requests may be made on behalf of patients. 6. Using case-based teaching as it arises in the course of the clinic; these competencies will be explicitly discussed.

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010) 7. Written and verbal reports from the resident will be evaluated by the Medical Oncology staff and Health Advocacy issues will be reviewed with feedback given.

Scholar:

1. Residents will participate in the weekly formal Urology Academic Half Day, and lead/participate on topics as assigned. 2. Residents will participate in weekly Urology Grand Rounds and lead/participate on topics as assigned. 3. Residents will participate in educational rounds and teaching sessions based on Medical Oncology/ Surgical Foundations prescribed curriculum and lead where indicated; to be assessed by attending Medical Oncology / Surgical Foundations staff. 4. Ongoing participation in the weekly Journal Club (September – June only) and weekly Medical Oncology rounds 5. Residents may seek research projects with faculty supervision and be directly assessed and mentored in their scientific methods, verbal and written communication skills and presentation skills of said research. 6. Residents will be assessed in their integration of contemporary best practices guidelines in Medical Oncology with day to day operations by faculty. 7. Residents will teach students, residents, the public and other health care professionals and be assessed by said groups through One45 assessment templates and ITERS.

Professional:

1. Residents will be observed in their interactions with other housestaff, their fellow residents, other services and with attending faculty. 2. Residents’ written documentation in the form of consultation notes, orders, and discharge notes will be reviewed with attending staff and feedback given face to face. 3. Residents will be observed in their interactions with patients and their families within the context of managing boundaries, and exhibiting ethical, courteous, compassionate respectful care. 4. Residents will be observed with regards to management of their own and other colleagues health and welfare. 5. Using case-based teaching, the Medical Oncologists and the resident will discuss issues related to patient diversity as well as shared decision making with patients based on patient concerns, beliefs and past experiences.

This document refers to the RCPSC Objectives of Training in Urology (2009) This document refers to the RCPSC Objectives for Surgical Foundations Training (2010)