Advanced Training Skills Modules August 2010
Advanced laparoscopic surgery for the excision of benign disease INTRODUCTION
This programme defines the training required to produce individuals with the skills required for the excisional treatment of benign gynaecological conditions using advanced laparoscopic surgical techniques. This is an advanced training program for a specified small group of clinicians to be trained to carry out high level laparoscopic surgery in this field. It is envisaged that people attaining these skills would serve as tertiary referral leads. This programme requires an average of two years intensive training and is separate from levels attained in the Benign Gynaecological Surgery: Laparoscopy ATSM. The trainee needs to assign at least 50% of their time for two years to be able to have the necessary skills at the end of training. Intermediate ultrasound training skills are required in gynaecology for this ATSM. (See Ultrasound training section).
Training in the module is competency-based, however, it is expected to take a least 18 months. Any trainee applying for training in this module will only be eligible if they have a minimum of 18 months of training remaining before their projected CCT date. Intermediate ultrasound training in the gynaecology
module will be undertaken as part of the ATSM. OUTLINE 1 Patient assessment and selection 2 Investigations 3 Non-surgical treatment modalities 4 Surgical treatments 5 Specialist urology 6 Specialist colorectal 7 Pain management 8 Generic competences (common to all advanced training skills modules)
Advanced Training Skills Modules August 2010
1 General assessment 1.1 History Objective Understand the different facets of obtaining a history of the woman’s condition.
General history.
Pain, fertility, sexual function, menstrual history.
Standardised questionnaires.
Quality of life questionnaires.
1.2 Examination Objective Competent at examination and appropriate recording of findings.
General.
Pelvic.
Rectal.
Advanced Training Skills Modules August 2010
2 Investigations
Objective To understand indications for and select correct tests, be able to interpret meaning of report and understand limitations for the following investigations:
Pelvic USS. Renal USS. MRI / CT. Contrast studies of the gastro-intestinal tract. Contrast studies of the upper and lower urinary tract. Endoscopy. Relevant blood tests. Relevant fertility tests Potential screening tests. Abdominal X-ray. DMSA scans 3 Non-surgical treatment modalities Objective To understand the indications, limitations and complications of the following treatment options Combined oral contraceptive pill. Progestagens. GnRH Analogues. Aromatase inhibitors. Analgesics and other pain management options. Immune modulators. Complementary therapies. Assisted reproductive techniques including IVF. Counselling
Advanced Training Skills Modules August 2010
4 Surgical procedures 4.1 Generic Objective To be able to perform and understand the place of the following
Appropriate laparoscopic entry techniques o Veress. o Hassan. o Palmer’s point. o Non-standard placement of ports.
Port site closure.
Safe use of appropriate energy source.
Suturing.
Knot tying o Intra-corporeal. o Extra-corporeal.
Specimen retrieval o Use of mocellator. o Posterior colpotomy. o Bags.
Tests for bladder and bowel integrity.
Recognise and initially manage complications o Urinary tract. o Gastrointestinal tract. o Haemorrhage. o Late complications.
4.2 Specific procedures Objective Understand indications for and be able to carry out the procedure Be able to counsel a woman appropriately Understand potential complications and be able to deal with them
Division of dense adhesions involving bowel.
Pelvic side-wall dissection.
Recto-vaginal dissection.
Utero-vesical dissection.
Advanced Training Skills Modules August 2010
Excision of endometriosis.
Repair of bladder.
Repair of sero-muscular layer of bowel.
Total laparoscopic hysterectomy.
Laparoscopic myomectomy.
Interruption of neural pathways where indicated
Laparoscopic pre-sacral neurectomy
Laparoscopic uterine nerve ablation / excision 5 Specialist urology Objective Understand indications for and be able to perform
Ureteric stenting (including double J).
Cystoscopy. Objective To have an understanding of and be able to counsel appropriately for
Ureteric anastamosis.
Ureteric re-implantation.
Urinary fistulae.
Advanced Training Skills Modules August 2010
6 Specialist colorectal Objective Understand indications for and be able to perform
Proctoscopy.
Sigmoidoscopy. Objective To have an understanding of and be able to counsel appropriately for:
Full thickness bowel repair.
Bowel resection.
Ileostomy.
Colostomy.
Ileostomy reversal.
Colostomy reversal.
Bowel fistulae. 7 Pain management Objective Understand principles of pain management
Psychology.
Drug treatment.
Other o Nerve blocks. o TENS. o Complementary therapy.
Advanced Training Skills Modules August 2010
8 Generic Generic skills Objective To be highly proficient with
Communication skills.
Maintaining good medical practice.
Maintaining trust.
Professional behaviour.
Ethics and legal issues.
Patient education and disease prevention.
Team working and leadership skills.
Clinical governance/risk management Research, audit and epidemiology
Objective To be able to understand and demonstrate appropriate skills and attitudes in relation to research
Review evidence.
Critically evaluate scientific studies and multicentre trials/systematic reviews. Objective To be able to understand and demonstrate appropriate skills and attitudes in relation to clinical audit
Define standard, prepare project, collate data.
Re-audit and close audit loop.
Formulate policy as a result of the audit. Objective To have an understanding of
Clinical Governance.
Risk management: evidence.
Audit.
Guidelines.
Structure of the NHS and ‘Principles of Management’.
Information use and management.
Advanced Training Skills Modules August 2010
1: Assessment of woman and selection process
Assessment of woman The trainee should be able to perform a thorough assessment of women with benign gynaecological conditions that pertain to excisional laparoscopic surgery. This includes: 1.1. History Learning outcomes: Understand the different facets of obtaining a history of the woman’s condition.
To be able to obtain a general history
To be able obtain a pelvic pain / menstrual / fertility/ bowel function history.
To be able to use standardised questionnaires
To be able to use quality of life questionnaires
Knowledge criteria Clinical competency
Professional skills and attitudes
Training support Assessment / Evidence
Understand symptoms that women may complain of. Able to break down of the history into its various components, such as dysmenorrhoea, dyspareunia, dyschezia, pelvic pain, lower backache. Understand that other associated gastrointestinal and urological symptoms should also be assessed. Able to ascertain fertility history and if the woman is trying for pregnancy. Knowledge including past investigations and treatment Relationship with other
Take an appropriate history Be able to present relevant history. Arrange for use of appropriate standardised QUOL questionnaires:
Ability to take an appropriate history Ability to use appropriate QUOL questionnaires and analyse them. The use of such scoring systems to assess severity and to monitor response to treatment. Importance of differential diagnosis such as urological or gastrointestinal disease.
Tailored clinical experience
Observation of cases, assisting and discussing cases with senior medical staff
Personal study Appropriate postgraduate education courses
Mini CEX Case based discussion Discussion groups Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency
Professional skills and attitudes
Training support Assessment / Evidence
medical conditions and psychosexual health. Understand how standardised questionnaires are devised Understand the significance of quality of life questionnaires Understanding of how questionnaires are validated.
Advanced Training Skills Modules August 2010
1.2. Examination Learning outcomes: Be able to carry out a competent examination
To be able to do a general examination
To be able to do a pelvic examination including standardised methods of assessment
To be able to do a relevant basic colorectal examination
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Understand the anatomy and innervation of the genital tract and the impact of disease on the organs. Examine findings relevant to benign gynaecological conditions including assessment of the posterior cul de sac.
Carry out an appropriate general, pelvic and rectal examination. Able to map areas of pain or abnormal masses in relation to underlying anatomical structures.
Ability to:
Carry out an appropriate general examination.
Carry out an appropriate abdominal and pelvic examination including new assessments methods as they are introduced into clinical practice.
Carry out an appropriate rectal examination especially with regard to rectovaginal endometriosis.
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff Personal study Appropriate postgraduate education courses
Mini CEX Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
1.3 Patient selection
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Patient selection for laparoscopic excisional surgery should demonstrate a thorough knowledge of the following:
1. Suitability of woman for laparoscopic procedure:
ASA score / fitness.
Assessment of suitability of condition for laparoscopic surgery.
Knowledge of appropriate preoperative investigations
Knowledge of appropriate alternative options.
Effect of previous surgery.
Impact of body mass
Knowledge of necessary laparoscopic equipment
3. Thorough counselling / consent of woman:
Alternatives
Risks
Benefits
Understand importance of appropriate selection of woman Have an understanding of how history, investigations and careful counselling impact on patient selection
Able to exhibit knowledge of selection criteria Able to apply knowledge of patient selection criteria to clinical situation.
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff Personal study Appropriate postgraduate education courses
Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
1 – Patient assessment and selection
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
History
Full menstrual history
Interpret quality of life questionnaires
Examination
Appropriate abdominal examination
Appropriate pelvic examination
Assessment of pelvic nodules
Perform a rectal examination
Patient selection
Counsel with regards different option
Counsel with regards to suitability for surgery
Carries out ASA score
(Grey out = not required)
Advanced Training Skills Modules August 2010
2: Investigations Objectives For the following investigations: 1.To understand indications and contraindications. 2 To select appropriate investigation. 3 To interpret the results. 4 To understand the limitations of the investigation. Pelvic USS. Abdominal USS. MRI / CT Scan. Plain x-ray of chest and abdomen. Contrast studies of the gastro-intestinal and urinary tracts. Colonoscopy. Cystoscopy. Blood tests including hormones to assess ovarian reserve and ovulation. Relevant fertility tests including semen analysis and tubal patency tests.
Knowledge criteria Clinical competency Professional skills and attitudes
Training support Assessment / Evidence
Indications for Imaging
Ultrasound
MRI
CT
Plain X-Ray
Contrast Studies of renal tracts
Contrast studies of gastro-intestinal tract
DMSA scans Indications for endoscopy
Sigmoidoscopy
Colonoscopy
Cystoscopy
Interpret images in consultation with imaging specialist Perform transvaginal ultrasound Perform sigmoidoscopy and cystoscopy Understand colonoscopy reports Order and interpret appropriate tests
Ability to explain findings and their significance Competently perform procedure Carry out the procedure Explanation of findings Correct interpretation and significance of results
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff
Personal study Appropriate postgraduate education courses
Satisfactory completion of the Intermediate Ultrasound module in gynaecological scanning OSATS in cystoscopy Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes
Training support Assessment / Evidence
Blood Tests Understand physiological and pathological processes affecting the following blood tests:
Haematological indices
Renal function Liver function Sex steroids CA125 Future markers Fertility tests
Understand indications and referral for tubal patency test, semen analysis for the partner
Advanced Training Skills Modules August 2010
Competence level
Level 1 Level 2 Level 3
2 – Investigations Date Signature Date Signature Date Signature
Interpret MRI pelvis
Report CXR
Report AXR
Report Contrast studies renal tract
Report contrast studies GI tract
Cystoscopy
Sigmoidoscopy
Colonoscopy
Interpret blood results
(Grey out = not required)
Advanced Training Skills Modules August 2010
3: Non-surgical treatment modalities
Objective: To understand the role of non-surgical modalities in the treatment of benign gynaecological conditions. Hormonal Treatments
COC Pill Progestagens GnRH analogues Aromatase Inhibitors
Non-Hormonal Treatments
Non-steroidal anti-inflammatories Tranexamic Acid Immune Modulators
Analgesics and other pain management options Haematinics Complementary therapies Assisted conception techniques Counselling
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Have a thorough understanding of
The principles of pharmacology.
The pharmacology of chemical substances that act upon benign gynaecological conditions.
The pharmacology and side-effects of analgesic drugs.
Indication for Hormonal Treatments
COC Pill Progestagens GnRH analogues Aromatase Inhibitors
Non-Hormonal Treatments Non-steroidal anti-
inflammatories Tranexamic Acid Immune Modulators
Analgesics Haematinics Complementary therapies Indication for assisted conception techniques
Appropriate knowledge Choose appropriate treatment Counsel woman accordingly
Refer and counsel appropriately Ability to choose appropriate treatment Develop knowledge base Ability to counsel woman
Able to exhibit knowledge of treatment selection
Counsel appropriately
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff
Personal study Appropriate postgraduate education courses
Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
3– Conservative treatments
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
Discussion of medical options
Give a subcutaneous injection
Give an intra-muscular injection
Advanced Training Skills Modules August 2010
4 Surgical procedures 4.1 Generic Objectives: To be able to perform and understand the place of the following
Appropriate laparoscopic entry techniques Veress Hassan Direct visual entry Palmer’s point Non standard placement of ports Port site closure
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Knowledge of relevant anatomy and pathopysiology. Detailed knowledge and understanding of the current controversies and theories of aetiology about all benign gynaecological diseases that pertain to laparoscopic excisional surgery.
Understand the advantages and pitfalls of Veress needle entry Hassan technique Direct visual entry Palmer’s point entry Understand the principles of port site closure and the need to avoid port site hernia or damaged underlying structures
Proficiency in Veress needle, Hassan and Palmer’s point entry techniques Knowledge of techniques Ability to safely close port sites using appropriate needles
Complete understanding and ability to apply principles to surgery Ability to perform procedures Understand the principles underlying these techniques Ability to close port sites
Appropriate reading and courses Tailored clinical experience and practice
Team observation Log of experience and competence OSATS for Palmers point and Hassan
Advanced Training Skills Modules August 2010
Safe use of appropriate energy source
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment/evidence
Understand the principles of electrosurgery, laser modalities, beam coagulators, ultrasound and other future energy sources.
Be able to demonstrate ability to use one modality effectively and have an understanding of the principles underlying all the others
Ability to safely perform these procedures and a thorough understanding of the safety checks required before activating the energy source Trouble shooting
Tailored clinical experience and appropriate theoretical training
Case based discussion
Suturing
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to competently suture pedicles and hollow viscii using laparoscopic needle holders Ability to undertake intracorporeal and extracorporeal knot tying
Proficiency in competently suturing and tying the appropriate surgical knots
Ability to perform these procedures Tailored clinical experience and practice
OSATS knot tying
Specimen retrieval
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Understand the use of tissue morcellation techniques, posterior colpotomy and tissue retrieval bag
Proficiency in the use of morcellator, undertaking posterior colpotomy and trans abdominal and trans vaginal removal of tissue using tissue retrieval bags
Ability to perform these procedures Tailored clinical experience and practice
Advanced Training Skills Modules August 2010
Tests for bladder and bowel integrity
Knowledge criteria Clinical competency Professional skills and attitdues Training support Assessment / Evidence
Ability to inspect bladder, ureter, small and large bowel for perforation or damage, recognition of this and undertake appropriate special tests such as air insufflation and use of dyes
Ability to carry out visual inspection of bowel, carry out air insufflation and dye tests. Ability to check integrity of bladder using visual inspection and dye tests. Ability to visually check the ureter through its pelvic course and pass the appropriate ureteric catheter.
Ability to perform these procedures Tailored clinical experience and practice
OSATS
Initial management of intraoperative complications
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Recognition of bowel and bladder complications. Assessment of these and ability if appropriate to perform primary repair. Understand the principles of more complex repairs such as segmental bowel resection and ureteric anastamosis and reimplantation. Recognise and be able to control haemorrhage.
Ability to undertake primary bladder closure. Understand principles of ureteric anastamosis. Ability to undertake with supervision primary small or large bowel perforation repair laparoscopically. Knowledge of the principles and techniques of segmental bowel resection and ureteric reimplantation. Ability to control major haemorrhage until appropriate help available and understand the principles underlying the repair of major vessels
Ability to perform these procedures Understand the principles underlying these procedures Ability to apply the appropriate vascular clamps and understand the principles underlying the repair of major vessels
Tailored clinical experience and practice
Case based discussion
Advanced Training Skills Modules August 2010
Management of late complications
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Recognition of delayed onset complications such as peritonitis, ileus, faecal contamination or urinary leakage. The ability to start appropriate initial management and understand the principles of subsequent management
Recognition of the signs and symptoms of intra-abdominal trauma and the use of appropriate investigations. The ability to seek appropriate support e.g General Surgeon, Urologist, Intensive Care Specialist
Ability to recognise and deal with intra-abdominal trauma
Tutorials, lectures and training
Case based discussion
4.2. Specific procedures
Objective Understand indications for and be able to carry out procedures outlined below Be able to counsel a woman appropriately Understand potential complications and be able to deal with them
Division of dense adhesions involving bowel
Repair of sero-muscular layer of bowel
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to undertake adhesiolysis using appropriate instruments or energy source, the ability to check for bowel integrity and appropriate suture of sero-muscular tears. Ability to explain to the risks and benefits of the procedure to be undertaken. Recognise and deal with complications such as bowel perforation, ischaemic damage or haemorrhage
Proficiency in adhesiolysis and appropriate suture repair of sero-muscular tears Appropriate counselling skills. Ability to recognise and deal with complications
Ability to undertake adhesiolysis and appropriate repair techniques Ability to counsel women appropriately Prompt response and proficiency
Tailored clinical experience and practice Tutorials, lectures Tutorials, lectures and tailored clinical experience
OSATS
Utero-vesical dissection
Repair of bladder
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to undertake dissection of the utero-vesical fold of peritoneum and reflection of the bladder Ability to excise the peritoneum overlying the bladder and fibrotic lesions such as infiltrating endometriotic deposits Recognition and suturing of bladder defects Recognition of urinary leakage post operatively
Proficiency in dissection of the bladder. Ability to excise fibrotic lesions of the dome of the bladder Ability to suture bladder defects Ability to recognise the signs and symptoms of urinary peritonitis or fistula formation
Ability to perform these procedures Appropriate post operative management
Tailored clinical experience and practice Lectures and tutorials
Excision of endometriosis
Pelvic sidewall dissection
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to excise superficial and deep endometriosis overlying pelvic structures, bowel and the pelvic sidewall using the appropriate instruments and energy sources Ability to dissect the pelvic sidewall to demonstrate the course of the pelvic ureter, the great vessels, uterine arteries and the root of the sigmoid colon
Proficiency in excision of superficial and deep endometriosis using the appropriate technology Proficiency in the dissection of the pelvic sidewall
Ability to excise superficial and deep endometriosis Ability to dissect the pelvic sidewall
Tailored clinical experience and practice Tutorials and lectures
OSATS OSATS
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Recognition of immediate and late post operative complications
Ability to recognise and undertake immediate management of complications, summoning appropriate specialist help as necessary
Appropriate clinical skills
Advanced Training Skills Modules August 2010
Rectovaginal dissection
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to recognise and excise infiltrating and nodular endometriosis of the rectovaginal septum and uterosacral ligaments. Recognition of the degree of obliteration of the posterior cul de sac and involvement of the rectum Ability to appropriately repair sero-muscular lesions of the intraperitoneal and extraperitoneal rectum and vaginal epithelium of the posterior vaginal fornix Understand risks of ischaemic damage and wound breakdown leading to fistula formation or faecal peritonitis
Proficiency in excisional techniques to allow a complete dissection of the rectovaginal space by identification of the appropriate anatomical landmarks such as the uterine arteries, uterosacral ligaments and ureters. The ability to recognise both partial and full thickness involvement of the rectum. The ability to undertake disc resection of the rectum with supervision and to appropriately assess the need for segmental resection Proficiency in suturing sero-muscular lesions of the intraperitoneal and extraperitoneal rectum and the ability to suture vaginal lesions laparoscopically or transvaginally Ability to recognise and undertake immediate management of complications, summoning appropriate specialist help as necessary
Ability to dissect the rectovaginal space and excise infiltrating and nodular endometriosis completely and safely. The ability to undertake rectal and vaginal repairs with appropriate supervision Ability to undertake repair of seromuscular defects in the bowel wall and complete vaginal repairs Appropriate clinical skills
Tailored clinical experience and practice Tutorials and lectures
Team observation Log of experience and competence OSATS Case based discussion
Advanced Training Skills Modules August 2010
Laparoscopic myomectomy
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Ability to assess the appropriateness of laparoscopic myomectomy, and to undertake the excision of subserous intramural and broad ligament fibroids. The ability to suture the defect using the appropriate intra and extra corporeal techniques. The ability to deal with haemorrhage from the uterine serosa and myometrium. The ability to remove the extirpated fibromyomata using the appropriate morcellation, posterior colpotomy or tissue retrieval bags Recognition of potential complications such as haemorrhage, disseminated intravascular coagulation and late uterine dehiscence
Proficiency in the assessment and removal of subserous, intramural and broad ligament fibroids. Proficiency in suturing uterine defects and techniques for the control of haemorrhage. Proficiency in use of morcellators, posterior colpotomy and tissue extraction bags Ability to recognise and undertake immediate management of complications, summoning appropriate specialist help as necessary
Ability to excise myomata Ability to suture uterine defects using intracorporeal and extracorporeal suturing techniques. Ability to use appropriate techniques for tissue extraction Appropriate clinical skills
Tailored clinical experience and practice Tutorials and lectures
Case based discussion OSATS
Advanced Training Skills Modules August 2010
Total laparoscopic hysterectomy
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Appropriate assessment of suitability of woman for total laparoscopic hysterectomy and the ability to undertake a total laparoscopic hysterectomy using a recognised technique and an understanding of suitable alternatives. Recognition of initial and late complications such as haemorrhage or damage to adjacent viscera
Proficiency in undertaking total laparoscopic hysterectomy. Ability to manage haemorrhage and initial treatment of damage to adjacent viscera. Recognition of late complications. Initiation of immediate treatment and summoning the appropriate help.
Ability to undertake a total laparoscopic hysterectomy using a recognised technique Appropriate clinical skills
Tailored clinical experience and practice Tutorials and lectures
Case based discussions OSATS
Interruption of Neural Pathways
Knowledge criteria Clinical competency Professional skills and attitudes Training support Assessment / Evidence
Understand the indications for and techniques of uterosacral nerve ablation, excision of uterosacral ligaments and pre-sacral neurectomy. Recognition of early and late complications such as haemorrhage, urinary retention, constipation
Proficiency in undertaking these procedures Ability to manage retroperitoneal haemorrhage, urinary retention and constipation
Ability to undertake these procedures Appropriate clinical skills
Tailored clinical experience and practice Tutorials and lectures
Case based discussion
Advanced Training Skills Modules August 2010
4 Surgical Procedures
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
Hassan terchnique
Palmer’s point entry
Use of tissue morcellator
Suture ovary closed
Ureteric dissection
Rectovaginal space dissection
Close bowel disc resection
Total laparoscopic hysterectomy
(Grey out = not required)
Advanced Training Skills Modules August 2010
5: Specialist urology Learning outcomes: 1. Have an understanding, knowledge of and be able to carry out
Cystoscopy
Inserion of urteric stents
2. Have an understanding of
Ureteric anastomosis Ureteric re-implantation Fistula management
Knowledge criteria Clinical competency Professional skills and attitudes
Training support Assessment / Evidence
Understand the indications for cystoscopy Have a knowledge of the surgical principles for the treatment of ureteric injury. Understand the investigation, and diagnostic criteria for fistulae. Understand the surgical principles of the repair and complications that may occur. Understanding of the correct investigations and treatments for ureteric obstruction and ureteric injury. Knowledge of when and how
Able to perform cystoscopy Determine correct indications for referral and have an understanding of the procedures and how to counsel women. Ability to diagnose fistulae and order appropriate investigations. Able to counsel women appropriately. Theoretical knowledge of management of ureteric problems. Ability to insert appropriate
Cystoscopy Assessment of women and appropriate counselling. Management of ureteric injury and obstruction.
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff
Personal study Appropriate postgraduate education courses
Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes
Training support Assessment / Evidence
to insert ureteric stents., Knowledge of the surgical principles of ureteric re-anastomoses and re-implantation techniques. Understands risks and management of voiding dysfunction post=operatively
ureteric stents. Correct counselling of a woman Able to advise on catheter management
Use of ureteric stents. Use of bladder ultrasound to assess bladder volume
Tailored clinical experience
5- Specialist urology
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
Cystoscopy
Ureteric stenting
Ureteric re-implantation
Ureteric re-anastomoses
(Grey out = not required)
Advanced Training Skills Modules August 2010
6: Specialist colorectal Learning outcomes: Understand the indications for and be able to perform
Proctoscopy
Sigmoidoscopy Learning outcomes: Have an understanding of the indications for and methods of performing
Full thickness bowel repair
Bowel resection
Ileostomy (and reversal)
Colostomy (and reversal)
Bowel fistulae
Knowledge criteria Clinical competency Professional skills and attitudes
Training support Assessment / Evidence
Understand the indications for and limitations of visual inspection of the lumen of the lower gastro-intestinal tract. Understand the principles of bowel resection, stoma formation and bowel anastamosis. Understand the principles and practice of post-operative care for women who have had bowel surgery.
Ability to perform proctoscopy and sigmoidoscopy. Be able to recognise normal mucosa and bowel stenosis. Knowledge of when to refer to a coloproctologist. Ability to communicate with women about the need for bowel surgery. Be able to explain the procedures which may be required, need for stoma, and reversal. Able to provide post-operative care for women who have had bowel surgery.
Proctoscopy and sigmoidiscopy. Communication skills. Post-operative care following bowel surgery
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff
Personal study Appropriate postgraduate education courses
Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
6 – Specialist colorectal
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
Proctoscopy
Sigmoidoscopy
Full thickness bowel repair
Ileostomy and reversal
Colostomy and reversal
(Grey out = not required)
Advanced Training Skills Modules August 2010
7: Pain management Learning outcomes: Have an understanding of the mechanisms of perception of and methods to treat pain.
Recording and mapping pain
Psychology
Drug treatment
Nerve blocks
TENS
Complimentary therapy
Knowledge criteria Clinical competency Professional and attitudes
Training support Assessment / Evidence
Understand theories of pain causation and perception. Understand the principles of pain mapping. Understand woman’s responses to and strategies for dealing with pain. Understand the pharmacological principles of analgesic drugs. Understand indications for and principles of the use of nerve blocks and TENS for analgesia.
Ability to accurately document woman’s descriptions of pain. Ability to prescribe effective and safe analgesia. Have observed nerve blocks and TENS use in a Pain Clinic. Knowledge of multidisciplinary pain management teams
Consultation skills Knowledge of pain management
Tailored clinical experience
Observation of, assisting and discussion with senior medical staff
Personal study Appropriate postgraduate education courses
Case based discussion Team observation Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional and attitudes
Training support Assessment / Evidence
Understand the contribution of complementary therapies for analgesia. When to refer to pain management teams
7- Pain management
Competence level
Level 1 Level 2 Level 3
Date Signature Date Signature Date Signature
Counselling for different treatments
Tens machine
Nerve blocks
(Grey out = not required)
Advanced Training Skills Modules August 2010
8 Generic skills
Communication, team working and leadership skills Objectives: Demonstrate effective communication with women and colleagues
Demonstrate good working relationships with colleagues Demonstrate the ability to work in clinical teams and have the necessary leadership skills
Knowledge criteria Clinical competency Professional skills and attitudes Training support
Evidence / Assessment
Communication
- how to structure an interview with a woman to identify: concerns & priorities expectations understanding & acceptance
- breaking bad news
- bereavement process and behavior Team working
- roles and responsibilities of team members
- factors that influence & inhibit team development
- ways of improving team working incl.
objective setting & planning
motivation and demotivation
organization
respect
- contribution of mentoring and supervision
Leadership
- qualities and behaviors
- styles
- implementing change / change management (see 7.5)
Be able to communicate both verbally and in writing with women and their relatives including;
breaking bad news
appropriate use of interpreters Be able to communicate both verbally and in writing with colleagues
Ability to communicate effectively with:
colleagues
women and relatives Ability to break bad news appropriately and support distress Ability to:
work effectively within a subspecialty team
lead a clinical team
respect other’s opinions
deal with difficult colleagues
Observation of and discussion with senior medical staff
Team observation Log of experience and competence Mini CEX Case based discussion
Advanced Training Skills Modules August 2010
Good Medical Practice and maintaining trust
Objectives: To inculcate the habit of life long learning and continued professional development To ensure trainee has the knowledge, skills and attitudes to act in a professional manner at all times
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
Continuing professional development Doctor-patient relationship Personal health Understand relevance of:
RCOG
GMC, Defence Unions, BMA
Specialist societies
STC & postgraduate dean Ethical principles
respect for autonomy
beneficence & non maleficence
justice Informed consent Confidentiality Legal issues
death certification
mental illness
advance directives, living wills
Be able to recognize and use learning opportunities Be able to gain informed consent for:
patient care and procedures
research
Ability to recognize and use learning opportunities Ability to:
learn from:
- colleagues
- experience
work independently but seek advice appropriately
deal appropriately with challenging behaviour
Understand:
ethical issues relevant to subspecialty
legal responsibilities Recognize; own limitations when personal health takes
priority over work pressure Ability to gain informed consent
Observation of and discussion with senior medical staff
Team observation Log of experience and competence Mini CEX Case based discussion)
Advanced Training Skills Modules August 2010
Teaching Objectives: Understand and demonstrate appropriate skills and attitudes in relation to teaching
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
Teaching strategies appropriate to adult learning RCOG core and advanced training relevant to subspecialty Identification of learning principles, needs and styles Principles of evaluation
Prepare and deliver a teaching session
small group (<10)
large group (>20)
at the bedside Teach practical procedures (incl. ultrasound)
Ability to communicate effectively Ability to teach postgraduates on topic(s) relevant to subspecialty using appropriate teaching resources Ability to organize a programme of postgraduate education e.g. short course or multidisciplinary meeting
Observation of and discussion with senior medical staff Appropriate postgraduate courses
Log of experience and competence
Clinical governance (CG) and risk management Objectives: Understand and demonstrate appropriate knowledge and skills in relation to CG and risk management
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
Clinical Governance
- organizational framework at local, SHA and national levels
- standards e.g. NSF, NICE, RCOG guidelines
- clinical effectiveness
principles of evidence based practice
types of clinical trial/evidence classification
Perform clinical audit
define standard based on evidence
prepare project & collate data
re-audit and close audit loop
formulate policy Develop and implement a clinical guideline
purpose and scope
identify and classify evidence
Ability to practice evidence based medicine Ability to perform a clinical audit relevant to subspecialty Ability to develop and implement a clinical guideline relevant to subspecialty Ability to report and investigate a
Observation of and discussion with senior medical staff and clinical governance team. Attendance at risk management meetings DH, RCOG and
Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
grades of recommendation
- guidelines and integrated care pathways
formulation
advantages and disadvantages
- clinical audit
- patient / user involvement Risk management
- incidents/near miss reporting
- complaints management
- litigation and claims management Appraisal and revalidation
- principles
- process
formulate recommendations
identify auditable standards Participate in risk management
investigate a critical incident
assess risk
formulate recommendations
debrief staff Perform appraisal
critical incident Ability to respond to a complaint in a focused and constructive manner. Ability to perform appraisal
Trust publications
Administration and service management Objectives: Display knowledge of the structure and organization of the NHS nationally and locally
Understand and demonstrate appropriate skills and attitudes in relation to administration and management
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
Organization of NHS services
Directorate, Trust
PCT, SHA Managed clinical network for subspecialty service Health and safety Management
strategy development
Develop and implement organizational change
development of strategy
formulate a business plan
manage project Be able to participate in recruitment
job specification
interview and selection
Ability to develop and implement organizational change Ability to collaborate with:
other professions
other agencies Develop interviewing techniques and those required for performance review
Observation of and discussion with senior medical and management staff Attendance at Directorate management meetings / interviews Management
Log of experience and competence
Advanced Training Skills Modules August 2010
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
business planning
project management Financial resource management Human resources
team building
appointments procedures
disciplinary procedures Scrutiny of organization
Healthcare Commission
PMETB / educational inspection visits
course
Information use and management Objective Demonstrate competence in the use and management of health information
Knowledge criteria Clinical competency Professional skills and attitudes Training support Evidence / Assessment
Input, retrieval and utilization of data recorded on clinical systems relevant to subspecialty Main local and national projects and initiatives in IT and its applications
NPfIT and Connecting for Health Confidentiality of data
principles and implementation
role of Caldicott guardian
Be able to use relevant
software
databases
web sites
digital recording media
Ability to apply principles of confidentiality in context of IT
Observation and discussion with senior medical staff World wide web
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