EPA: Thyroid Disease

EPA: Thyroid Disease

Includes the following conditions:

Follicular neoplasm

Hyperthyroidism

Papillary thyroid cancer

Thyroid nodule

Evaluatee Name*

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Evaluator Name*

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Date of Assessment*

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

Preoperative: Evaluation*

OBTAINS H&P (sx of thyroid hormone deficiency/excess) w/ cultural humility. ORDERS BASIC TFTs, REQ ASSIST for comprehensive workup. Develops differential for thyroid nodule/neck mass (includes common disorders). Unsure how to interpret US nodule findings

Evaluates pt presenting w/ thyroid disease/nodule, ORDERING & INTERPRETING lab testing & imaging/biopsy results as indicated . Articulates COMPREHENSIVE thyroid nodule workup. Describes some high-risk US features of thyroid nodules.

FORMULATES PERIOP PLAN of STRAIGHTFORWARD hypo- and hyperthyroidism. Articulates indications for molecular testing of indeterminate thyroid nodules & interprets results. Describes high- & low-risk US patterns of thyroid nodules

Develops COMPREHENSIVE plan for papillary/follicular thyroid CA, including CND and LND. Articulates INDICATIONS FOR NODAL DISSECTION in CA. Understands key differences in complex disease (Graves disease/thyroid storm), & use of medical or surgical tx

Not applicable/not observed

Preoperative: Evidence Based Management*

Identifies relevant EVIDENCE-BASED GUIDELINES for the management of thyroid disease

ELICITS PATIENT PREFERENCES to guide evidence-based care

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

Describes the expected outcome of NONOPERATIVE MANAGEMENT of papillary thyroid cancer and selects a patient for whom that would be an evidence-based option

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*

Please provide feedback to the trainee: specify the steps to achieve the next level of autonomy.

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