Parathyroid Disease

Parathyroid Disease

Includes the following:

Primary Hyperparathyroidism (not included in scope: hypercalcemia of malignancy)

Evaluatee Name*

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Evaluator Name*

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Date of Assessment*

Phase of Care*

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Intraoperative

Postoperative

Preoperative/Nonoperative

Preoperative: Evaluation*

OBTAINS H&P relevant to parathyroid dx (sx of primary hyperparathyroid) w/ cultural humility. ORDERS BASIC parathyroid function tests (PTH, Ca), REQUIRING ASSISTANCE FOR COMPREHENSIVE workup. Develops DDx for hyperCa that includes common disorders.

Diagnoses STRAIGHTFORWARD primary hyperparathyroidism in a patient based on lab evaluation.

Applies a COST-EFFECTIVE, EVIDENCE-BASED diagnostic evaluation for parathyroid disease.

Manages patient with parathyroid disease with COMPLEX COMORBIDTIES OR COMPLICATING FACTORS. Diagnoses an unusual presentation of primary hyperparathyroidism (eg, normohormonal and normocalcemic) based on an ADVANCED UNDERSTANDING of lab evaluation.

Not applicable/not observed

Preoperative: Evidence Based Management*

IDENTIFIES relevant evidence-based guidelines for the management of parathyroid disease

ELICITS PATIENT PREFERENCES to guide evidence-based care

APPLIES current guideline-based indications for operative treatment of primary hyperparathyroidism

CRITICALLY APPRAISES the literature and considers how to apply it in nuanced clinical situations.

Proposes referral to specialists for a patient with COMPLEX parathyroid disease (eg, MEN syndromes, suspected parathyroid carcinoma)

Not applicable/not observed

Case Difficulty*

Straightforward

Moderate

Complex

Intraoperative: Anatomy*

Identifies NORMAL NECK ANATOMY but needs assistance to identify normal parathyroid glands. Describes the expected route of the recurrent laryngeal nerves

Describes normal locations of the superior and inferior glands but REQUIRES ASSISTANCE TO IDENTIFY normal glands; describes some locations of ectopic glands. Identifies the recurrent laryngeal nerve and describes location of a nonrecurrent nerve.

DESCRIBES most sites of ECTOPIC parathyroid glands.

Describes operative maneuvers to IDENTIFY ECTOPIC parathyroid glands.

Intraoperative: Steps of Operation*

PERFORMS INITIAL STEPS, such as dividing the layers of the neck down to the relevant tissue, with direct instruction, REQUIRES PROMPTING to identify the appropriate plane. ASSISTS WITH EXPOSURE for dissection of the thyroid and parathyroid glands.

Performs initial steps, dividing the layers of the neck down to the relevant tissue, identifying tissue planes in the neck, and EXPOSING the thyroid and parathyroid GLANDS. REQUIRES PROMPTING to continue making PROGRESS during a STRAIGHTFORWARD operation.

Moves fluidly through the course of a STRAIGHTFORWARD thyroid or parathyroid operation and ANTICIPATES THE NEXT STEPS without prompting.

Mobilizes the thyroid, identifying/protecting CRITICAL structures; Identifies most or all parathyroid glands and can DIFFERENTIATE NORMAL AND ABNORMAL glands

Intraoperative: Technical Skills*

Reapproximates the soft tissues with DIRECT GUIDANCE. Displays coordinated hand movements for SIMPLE maneuvers, though INEFFICIENTLY and under direct instruction

Usually demonstrates CAREFUL tissue handling and COORDINATION of both hands

Smoothly dissects through the layers of the neck down to the relevant structures, visualizing tissue planes and ADAPTING TISSUE HANDLING BASED ON TISSUE QUALITY

Manages CHALLENGING ANATOMY or DIFFICULT dissections calmly and thoughtfully

Intraoperative: Problem-solving*

ASSISTS with exposure for dissection of the parathyroid glands

Interprets STRAIGHTFORWARD RESULTS OF INTRAOP PTH testing, if used

Interprets intraoperative PTH testing when the level increases or fails to drop, if used

MODIFIES SURGICAL PLAN BASED ON NEW INFORMATION discovered intraoperatively (eg, unexpected suspicious adenopathy, extrathyroidal invasion, lack of expected drop in PTH level, devascularized parathyroid gland after thyroid dissection)

Intraoperative: Communication with Others*

RESPECTFULLY ENGAGES in culturally sensitive communication with all members of the OR team. Demonstrates UNCERTAINTY about the necessary EQUIPMENT for the operation.

CLEARLY COMMUNICATES with all members of the OR team. Identifies the standard equipment for the operation but REQUIRES ASSISTANCE TO COORDINATE with perioperative staff to ensure it is available.

DESCRIBES POTENTIAL INTRAOP ADJUNCTS (eg, ET tube for nerve monitoring, access and timing of blood draws for intraoperative PTH, gamma probe).

COORDINATES with OR team to use INTRAOP ADJUNCTS effectively. Communicates clearly and respectfully in CRISIS SITUATIONS (eg, difficult airway, unexpected bleeding, decompression of neck hematoma)

Not applicable/not observed

Postoperative: Management*

Writes postop orders, provides PACU staff with contact information, and reviews postop lab studies, REQURING ASSISTANCE TO INTERPRET. Understands the need for thyroid hormone and calcium supplementation and selects the dose with assistance.

OVERSEES ROUTINE POSTOP CARE, including determining need for and dose of calcium or thyroid hormone supplementation.

AS ABOVE and assists with patient-specific barriers to care.

Critically appraises and applies EVIDENCE, ADAPTING TO COMPLEX CLINICAL SCENARIOS and tailoring recommendations to a patient's preferences and needs

Not applicable/not observed

Postoperative: Complications*

DESCRIBES COMMON complications of thyroid and parathyroid operations

RECOGNIZES COMMON SIGNS AND SYMPTOMS of common complications of thyroid and parathyroid operations. Verbalizes steps to manage a postop neck hematoma with airway compromise

EVALUATES AND MANAGES COMMON early and late complications of parathyroid operations, including hypocalcemia, hoarseness or vocal changes, and laryngeal nerve injury.

Quickly responds to COMPLEX OR HIGH-ACUITY POSTOP EMERGENCIES such as an expanding neck hematoma

Not applicable/not observed

Postoperative: Communication with others*

Attends and, if requested, presents at an interdisciplinary conference. Respectfully requests a consultation with endocrinology for ongoing treatment.

COMMUNICATES POSTOP PLAN to a patient/caregiver(s) and other health care team members

Identifies COLLABORATING SPECIALTIES to help formulate a postop plan of care (eg, endocrinology).

Ensures participation of collaborating specialties and COORDINATES their RECOMMENDATIONS at an interdisciplinary cancer care conference to synthesize a patient care plan, RESOLVING CONFLICT when needed

Not applicable/not observed

Overall Performance*

Based on your observation, what level of autonomy would you trust the resident to manage this surgical condition or perform this procedure 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*

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