EPA: Gallbladder Disease

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.

Select or enter value

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 an H&P with cultural humility and DEVELOPS DIFFERENTIAL for a patient with UNCOMPLICATED gallbladder (GB) disease in elective and emergent settings. Demonstrates understanding of the BASIC elements of GB anatomy.

Evaluates a patient with GB disease, interpreting lab values and imaging studies. DEVELOPS PLAN for managing a patient with UNCOMPLICATED GB disease.

Independently develops & concisely presents COMPREHENSIVE management plan for both COMPLICATED & UNCOMPLICATED GB disease, considering whether nonoperative management is indicated.

MANAGES a patient with COMPLICATED GB disease (eg, severe cholecystitis, choledocholithiasis post R-Y gastric bypass) or a medically complex patient (eg, sepsis, anticoagulation use, cardiac dysfunction), customizing use of nonoperative management.

Not applicable/No observed

Preoperative: Communication with Patient*

Respectfully COMMUNICATES BASIC FACTS but inconsistently uses applicable language services & audio/visual aids.

Communicates basic facts of a plan for uncomplicated GB disease; customizes communication to overcome barriers and cultural differences; CONSISTENTLY USES APPLICABLE LANGUAGE SERVICES & AUDIO/VISUAL AIDS.

Communicates across barriers and cultural differences to elicit PERSONALIZED CARE PLAN for GB disease in a shared decision-making process for STRAIGHTFORWARD presentation.

CUSTOMIZES COMMUNICATION based on a patient’s characteristics and preferences across barriers in CRITICAL OR LIFE-THREATENING situation; manages and DE-ESCALATE CONFLICT with a difficult or hostile patient/caregiver.

Not applicable/not observed

Preoperative: Work-up*

Demonstrates BASIC AWARENESS of costs of care as they relate to diagnostic and treatment options, including radiologic and lab assessments for biliary disease.

Demonstrates understanding of health care cost challenges but suggests DUPLICATE OR UNNECESSARY test(s).

Selects preoperative imaging and testing to diagnose GB pathology in RESOURCE AND TIME-EFFICIENT MANNER; distinguishes the cost and outcome differences associated with various treatment strategies.

TRIAGES treatment of GB disease with consideration of patient circumstances and preferences (comorbidities, socioeconomics).

Not applicable/not observed

Preoperative: Evidence Based Management*

Accesses evidence and considers patient preference in determining the best approach for managing GB pathology at a BASIC LEVEL (eg, operative vs nonoperative management).

INCORPORATES PUBLISHED EVIDENCE regarding the cost-effective management of patients presenting with gallstone disease.

APPLIES PUBLISHED GUIDELINES regarding the workup and management of a complex presentation of GB disease and INCORPORATES PATIENT PREFERENCE into the plan.

APPLIES CURRENT PUBLISHED GUIDELINES regarding the workup and management of GB disease, considering nuances and exceptions in a COMPLEX SITUATION.

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 for a STRAIGHTFORWARD CHOLECYSTECTOMY, providing information about risks, benefits, and alternatives; COMPLETELY DOCUMENTS the discussion.

Conducts an informed consent discussion for a straightforward cholecystectomy with cultural humility; completely documents the discussion related to the operative management of GB disease.

Conducts an informed consent discussion for a complex or emergent cholecystectomy with cultural humility, eliciting patient preferences and documenting risks and benefits individualized to the patient.

Not applicable/not observed

Intraoperative: Anatomy*

Describes the anatomic structures and relationships in gallbladder (GB) surgery (eg, cystic duct, cystic artery, hepatocystic triangle) and identifies them with assistance in a routine case.

Identifies variations in cystic duct and artery anatomy in a straightforward case and articulates their implications for the operation.

Identifies variations in cystic duct and artery anatomy in a setting of inflammation or scarring but requires assistance to adapt the operative approach in response to variant anatomy.

Adapts to unexpected variant anatomy in a complex cholecystectomy (eg, inflamed, shortened cystic duct) and changes the operative approach (subtotal or dome-down).

Intraoperative: Technical Skills*

Safe but tentative instrument handling, lack of 2-hand coordination, inefficient suturing & knot tying. Articulates sharps safety, safe surgical energy use, & surgical field sterility. Centers operative field with camera (freq adjustments & reminders).

Places trocars after initial entry & closes skin independently. REQUIRES GUIDANCE for port site triangulation, abdominal safe entry, clip placement. REQUIRES REDIRECTION to maintain optimal plane. Careful tissue handling & uses 2-hand coordination.

Careful tissue handling, dissects cystic duct & artery efficiently, obtains critical view of safety, places clips accurately w/o assist in routine & some difficult cases. Identifies dissection plane (remove GB from liver bed) accurately (routine case).

Functions as TA for case w/ normal anatomy while recognizing when technical requirements necessitate them to take over. Performs IOC safely in presence of scarring & inflammation. Analyzes how instrument choice affects the overall procedure cost.

Intraoperative: Steps of Operation*

Describes the basic steps of the operation and the critical view of safety. Requires active instruction to move the operation forward.

Provides a basic description of the operative plan but omits some steps. Moves the operation forward, usually proceeding to the next step of the procedure, though sometimes requires direction.

Performs lap chole safely (normal anatomy & minimal inflammation), identifying critical view of safety. Moves fluidly through case, anticipates steps and logistical needs and clearly communicates w/ OR team. Performs IOC independently in a routine case.

Adapts operative technique to tissue quality and case complexity; identifies the correct plane, dissects the cystic duct and artery, and obtains the critical view of safety in the presence of scarring and inflammation.

Intraoperative: Complications*

Identifies positioning options but cannot name factors to select one over another; recognizes importance of protecting against nerve & pressure injuries but cannot describe the resulting morbidity. REQUIRES ASSISTANCE to control bleeding or perform IOC.

Recognizes when deviation from the initial operative plan (eg, conversion to open or subtotal) is required.

Devises and implements a plan when deviation from initial operative plan (conversion to open procedure or subtotal chole) is required. Implements early management steps, including calling for assistance, when an intraop complication is identified.

Not applicable/not observed

Postoperative: Complications*

Evaluates common postop complication such as fever or hypotension, requiring assistance to recognize and evaluate GB-specific or severe complications. Alerts supervisors about postop complications & initiates management with supervision.

Recognizes deviation from normal postop recovery (differential may contain omissions). Manages simple postop problem independently (eg, fever, tachycardia). Recognizes but requires assistance to manage GB-specific or more severe postop complications.

Recognizes all postop complications (biliary leak or injury), & completes the necessary workup for these problems independently in straightforward patient. Evaluates postop problems with complex medical condition, requires supervision for management.

Manages GB-specific and complex postop problems (eg, biliary leak, CBD injury), even in patients with comorbid conditions. Directs interdisciplinary care to manage a patient experiencing complications.

Not applicable/Not observed

Postoperative: Communication with Patient*

Communicates basic aspects of the operative procedure and standard postop instructions to a patient/caregiver(s) but needs prompting to clarify expected outcomes and the anticipated treatment course.

Communicates details of the operative procedure and postop instructions to a patient/caregiver(s) but omits some elements when discussing expected outcomes and the overall anticipated treatment course.

Communicates customized postop instructions and updates to a patient/caregiver(s) using a variety of methods to ensure understanding; discusses unexpected findings or changes to the intended plan with cultural humility.

Manages conflict between patient, caregiver(s), and the health care team. Customizes emotionally difficult news (eg, changes to the operative plan, adverse outcome, end-of-life discussion) to a patient/caregiver(s) with care and cultural humility.

Not applicable/not observed

Postoperative: System Based Practice*

Describes different models of health care coverage in the U.S. and basic components of documentation required for billing and coding for GB disease patients.

Recognizes the influence of health care system financing structures on the postop care of the GB disease patient (eg, global period, care of patients requiring initial percutaneous drainage).

Analyzes how different treatment strategies (early vs delayed cholecystectomy in pancreatitis, operative vs endoscopic management of choledocholithiasis) impact outcomes and costs of care.

Selects a method of postop follow-up, considering case complexity, health care system cost, and patient wishes and resources (eg, telehealth, transportation challenges).

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