EPA: Cutaneous and Subcutaneous Neoplasms

Evaluatee Name (Last, First)*

Enter resident starting with last name. Once a form has been submitted, the resident will receive a copy of the evaluation.

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Phase of Care

UPDATE! You can only select one phase of care. Complete an assessment for each phase of case separately.

Intraoperative

Postoperative

Preoperative/Nonoperative

For each category, select the statement that best describes the resident behavior for this patient encounter.

Preoperative: Evaluation*

Obtains H&P w/ cultural humility, including focused derm exam. DEVELOPS DIFFERENTIAL including most common cutaneous & subcutaneous neoplasms but MAY OMIT LESS COMMON DIAGNOSES. DESCRIBES THE “ABCDE” OF A SKIN LESION that is concerning for malignancy

Evaluates/identifies risk factors (fam hx/environmental exposures). Orders/interprets imaging & other diagnostic tests. Understands DIFFERENCES BETWEEN MELANOMA & NONMELANOMA REGARDING TREATMENT & additional tests needed for ACCURATE STAGING WORKUP.

Develops & COORDINATE TX PLAN, including OP PLAN, CONSIDERING COMORBIDITIES (eg, no SLNB in those unable to tolerate dissection/adj therapy). Describes additional labs/imagining studies for COMPREHENSIVE STAGING W/U.

SYNTHESIZES ALL INFORMATION to develop a plan for managing patient with a COMPLEX CUTANEOUS OR SUBCUTANEOUS NEOPLASM/CONDITION (eg, localized or metastatic melanoma, Merkel cell carcinoma, large subcutaneous mass)

Not applicable/not observed

Preoperative: Communication with Patient*

Respectfully COMMUNICATES BASIC FACTS about the condition to a patient/caregiver(s) but INCONSISTENTLY USES APPLICABLE LANGUAGE SERVICES & AUDIO/VISUAL AIDS.

Respectfully COMMUNICATES BASIC FACTS about the diagnosis to a patient/caregiver(s); USES APPLICABLE LANGUAGE SERVICES & AUDIO/VISUAL AIDS.

CUSTOMIZES COMMUNICATION based on individual patient characteristics and preferences ACROSS BARRIERS & CULTURAL DIFFERENCES IN A COMPLEX SITUATION; MANAGES & DE-ESCALATES CONFLICT WITH DIFFICULT OR HOSTILE patient or caregiver.

Not applicable/not observed

Preoperative: Biopsy*

Describes 1 or 2 biopsy techniques.

Gathers needed instruments and equipment & initiates biopsy of suspicious skin lesion.

Describes and performs a punch biopsy; describes and initiates other biopsy techniques.

Performs or directs performance of optimal biopsy technique for suspicious skin lesion. Anticipates when primary closure will not be feasible or high risk and develops a plan for closure (eg, local flap coverage, collaboration with other specialists)

Not applicable/not observed

Preoperative: Consent*

Communicates the elements of an informed consent discussion but OMITS SOME ELEMENTS when documenting the discussion

Communicates the elements of an informed consent discussion in a STRAIGHTFORWARD CASE and completely documents the discussion

Conducts an informed consent discussion WITH CULTURAL HUMILITY AND COMPLETELY DOCUMENTS the discussion related to operative management

Conducts an informed consent discussion for a COMPLEX LESION EXCISION OR RECONSTRUCTION with cultural humility; ELICITS PATIENT PREFERENCES; documents RISKS AND BENEFITS INDIVIDUALIZED TO THE PATIENT

Not applicable/not observed

Preoperative: Communication with Others*

IDENTIFIES SPECIALTIES involved in interdisciplinary care, including medical oncology and radiation therapy, but NEEDS GUIDANCE TO UNDERSTAND SEQUENCING OF APPROACHES.

ATTENDS AN INTERDISCIPLINARY CARE CONFERENCE and PRESENTS INFORMATION FROM A SURGICAL PERSPECTIVE to other specialists (eg, medical oncology, radiation oncology, pathology, radiology)

PRESENTS PATIENT CASES AT AN INTERDISCIPLINARY CARE CONFERENCE and DISCUSSES CARE OPTIONS WITH OTHER SPECIALISTS (eg, medical oncology, radiation oncology, pathology, radiology)

LEADS & COORDINATES INTERDISCIPLINARY CARE CONFERENCE, discussions w/ other specialists (as above) & RESOLVING CONFLICT WHEN NEEDED. Collaborates w/ other providers to formulate patient-centered op plan for all common skin neoplasms.

Not applicable/not observed

Intraoperative: Steps of Operation*

REQUIRES ACTIVE INSTRUCTION to move the operation forward. PERFORMS SUPERFICIAL WOUND CLOSURE.

MARKS OUT THE CORRECT MARGINS of excision for a skin neoplasm with active help. Performs WLE & SLNB in STRAIGHTFORWARD CASE WITH GUIDANCE. Interprets single-node lymphoscintigraphy for SLNB. Correctly orients the specimen for pathology with assistance.

Positions pt to expose op field & all associated sites (eg, donor sites); MARKS OUT INDICATED MARGINS based on lesion type. PERFORMS WLE & SLNB W/ MINIMAL GUIDANCE; ANTICIPATES NEXT STEPS & logistical needs.

Independently marks out indicated margins of excision for skin neoplasms. PERFORMS WIDE LOCAL EXCISION AND SLNB IN STRAIGHTFORWARD AND COMPLEX lesions.

Intraoperative: Technical Skills*

Makes a skin incision along a marked OUTLINE DRAWN BY A SUPERVISOR. Identifies tissue planes WITH ACTIVE GUIDANCE AND RETRACTION. Handles instruments INEFFICIENTLY AND WITH LIMITED DEXTERITY; displays INCOMPLETE UNDERSTANDING of tissue handling.

Completes tissue dissection without violating the lesion. Demonstrates INCONSISTENT skin and subcutaneous TISSUE-HANDLING skills. REQUIRES ASSISTANCE to control bleeding.

Demonstrates FAIRLY SMOOTH TECHNICAL movements, hand coordination, and careful tissue handling. Respects tissue planes to MINIMIZE TRAUMA

Positions the patient to expose the surgical field while minimizing risk of iatrogenic injury. INDEPENDENTLY PERFORMS PRIMARY CLOSURE, SIMPLE RECONSTRUCTION, AND SKIN GRAFTING.

Intraoperative: Decision Making*

IDENTIFIES THE BASIC ANATOMY of the skin and subcutaneous tissues. ASSISTS with surgical positioning, patient preparation, and adequate exposure with retraction.

DESCRIBES UNEXP OR findings (in-transit melanoma, LAD not seen preop, or atyp lipomas), CAN’T IDENTIFY in OR. KNOWS POSITIONING options (CAN’T name factors to select one) and to PROTECT FROM NERVE/PRESSURE INJURY (CAN’T describe resulting morbidity)

RECOGNIZES UNEXPECTED INTRAOP findings (in-transit melanoma, LAD not identified preop, or atypical lipomas) but NEEDS DIRECTION TO MODIFY op plan. Considers LOCATION OF IMPORTANT STRUCTURES & PRESERVES them during excision (eg, spinal accessory nerve).

Positions the patient to expose the surgical field while MINIMIZING RISK OF IATROGENIC INJURY. INTEGRATES UNEXPECTED INTRAOP findings (in-transit melanoma, LAD not identified preop, or atypical lipomas) and MODIFIES THE OPERATIVE PLAN.

Intraoperative: Communication with Others*

Demonstrates RESPECT FOR & ENGAGES IN COMMUNICATION with all members of OR team. Demonstrates UNCERTAINTY ABOUT NECESSARY EQUIPMENT for case.

COMMUNICATES CLEARLY WITH ALL MEMBERS of the health care team in the OR. Demonstrates UNDERSTANDING OF NECESSARY EQUIPMENT BUT REQUIRES ASSISTANCE TO COORDINATE w/ periop staff to ensure it is available.

COLLABORATES WITH PLASTIC SURGERY for reconstructive options and WITH NUCLEAR MEDICINE for SLNB. COORDINATES WITH PERIOPERATIVE STAFF to ensure most necessary equipment is available and ready to use.

COORDINATES WITH PERIOPERATIVE STAFF IN ADVANCE to ensure that all necessary equipment is available and ready for use. Recognizes when complex wound closure is required and PROSPECTIVELY COORDINATES WITH OTHER SPECIALISTS.

Postoperative: Communication with Patient*

Provides updates & ANSWERS STRAIGHTFORWARD questions from patient/caregiver(s) in respectful & understandable way

CONVEYS POST-ENCOUNTER PLAN that includes postop patient care needs, outcome expectations, and follow-up

ENGAGES IN SHARED DECISION-MAKING with a patient/caregiver(s), integrating unique goals of care

Engages in post-encounter shared decision-making with a patient/caregiver(s), integrating unique goals of care AND TREATMENT OPTIONS (eg, metastatic melanoma, unresectable neoplastic recurrence)

Not applicable/not observed

Postoperative: Management*

Communicates a BASIC POSTOP PLAN to a patient/caregiver(s), NEEDING PROMPTING TO CLARIFY EXPECTED OUTCOMES and the anticipated treatment course

OVERSEES ROUTINE postop care, including use of multimodal pain management strategies. DOES NOT INDEPENDENTLY DEVELOP A POSTENCOUNTER PLAN that includes postop patient care needs, outcome expectations, and follow-up

DEVELOPS A POSTENCOUNTER PLAN that includes patient care needs, outcome expectations, and follow-up but omits some elements when discussing expected outcomes and the overall anticipated treatment course

COMMUNICATES A POSTENCOUNTER PLAN to a patient/caregiver(s) with cultural humility, including wound care, surveillance, and follow-up of malignant lesions per evidence-based treatment guidelines

Not applicable/not observed

Postoperative: Evidence-based*

ACCESSES EVIDENCE-BASED GUIDELINES for treatment of cutaneous and subcutaneous neoplasms

DESCRIBES SOME ELEMENTS OF EVIDENCE-BASED TREATMENT GUIDELINES for benign or malignant cutaneous/subcutaneous neoplasms

USES EVIDENCE-BASED TREATMENT GUIDELINES TO OUTLINE TREATMENT options for malignant neoplasms, requiring guidance for complex presentations (eg, metastatic melanoma, unresectable neoplastic recurrences)

CRITICALLY APPRAISES AND APPLIES EVIDENCE, adapting the plan based on a nuanced presentation

Not applicable/not observed

Postoperative: Complications*

DESCRIBES COMMON postop complications (hematoma or infection), REQUIRING HELP to articulate or recognize signs of these complications

RECOGNIZES COMMON postop complications (hematoma, seroma, & infxn), REQUIRING ASSISTANCE TO MANAGE them.

RECOGNIZES AND MANAGES EARLY postop complications such as seroma, hematoma, or infection; RECOGNIZES LATE FINDINGS like recurrent disease.

RECOGNIZES AND MANAGES BOTH EARLY AND LATE postop complications, such as seroma, hematoma, infection, and recurrences; biopsies a lesion suspicious for recurrence

Not applicable/not observed

Postoperative: Care Coordination*

ATTENDS AND, IF REQUESTED, PRESENTS AT AN INTERDISCIPLINARY conference when involved in the care of a patient with a skin neoplasm. Respectfully REQUESTS A CONSULTATION with medical and radiation oncology for adjuvant treatment of a malignant neoplasm

PARTICIPATES IN AN INTERDISCIPLINARY cancer care conference. Assists with patient-specific barriers to care, such as access to wound VACs.

ASSISTS IN COORDINATING an interdisciplinary cancer care conference

COORDINATES A TREATMENT PLAN AS OUTLINED IN AN INTERDISCIPLINARY cancer care conference

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to perform this task at the NEXT encounter?

Limited Participation: Learner has basic knowledge and skills, attending does show and tell

Direct Supervision: Attending provides active help

Indirect Supervision: Attending provides passive help

Practice Ready: Attending is available but is not needed for routine cases/presentations, but input may be needed for complex cases

Comment*

Please add comment on why you selected the answer above. Specifically note what steps the resident can take to achieve the next level of autonomy.