Curriculum/Goals and Objectives
The University of Toronto Adult Critical Care Medicine Residency Program is continuously developing new educational initiatives informed by the best available evidence in medical education. Examples of these initiatives include a recent renewal of our academic-half day (AHD) program, a re-introduction of simulation-based training in our curriculum, and a better, more structured oversight of trainees’ scholarly projects.
In 2017, we initiated a complete renewal of our formal educational program of academic-half days (AHD). The main objectives of this initiative were threefold: 1- to increase trainee’s engagement during AHD teaching; 2- to align AHD teaching with the CBME framework, including the preliminary Professional Entrustable Activities (EPAs) and the 5 stages of training proposed by the Royal College; and, 3- to engage additional critical care medicine faculty and trainees in the design and delivery of the curriculum. We have now completed the planning of a series of learning modules that will be fully implemented in July 2018. Thus far, we have engaged two dozen of faculty and trainees in the planning process. The curriculum is therefore based on multiple perspectives and expertise across our Division. We have also piloted different session formats over the past few months to refine the curriculum and maximize trainees’ engagement during each AHD session.
In parallel with the AHD curriculum renewal, we have relaunched our critical care simulation-based training. The overall goals and objectives of the simulation-based curriculum include the following: 1- to provide a safe learning environment where critical care trainees can develop and demonstrate their ability to integrate the multiple competencies that are required for the acute management of complex, unstable critically ill patients; 2- to provide our critical care trainees with informative feedback focused on the integration of these competencies; 3- to design a curriculum that addresses a range of content areas relevant for critical care practice, focusing on areas not adequately covered by clinical exposure during core ICU rotations; 4- to increase our local simulation human capacity by expanding the number of critical care physicians involved in simulation-based medical education. Trainees can now anticipate participating in 8-10 simulation sessions annually (involving mostly full-body manikin simulators, but also part-task trainers and simulated patients), based on a curriculum spreading over 2 years.
In 2015, the University of Toronto Adult Critical Care Medicine Residency Program decided to formalize the procedures surrounding the completion of a scholarly project by the residents. The objectives of this initiative were to provide better guidance and support to the residents in order to optimize their scholarly experience, to maximize the residents’ chances of completing a project with significant impact and in a timely manner, and to provide early mentoring to candidates interested in an academic career. Through in-person meetings with the Scholarly Lead, written resources documenting key steps for the successful completion of a project, and scholarly sessions involving Faculty and trainees to discuss preliminary ideas and near-completed projects, trainees are now better equipped to succeed in their scholarly endeavours.
Through these initiatives, we aim to provide to our trainees the best possible educational experience. We are committed to review and readjust our curriculum continually, based on faculty and trainees’ feedback. Above all, we hope to create an environment where trainees feel welcomed and engaged during their critical care training and beyond.
Program Teaching Rounds
Trainees are dismissed from their clinical responsibilities to attend the following mandatory teaching rounds:
- Academic Half-day Didactic lectures (Each Tuesday at 1400)
During the academic year, the residents attend a mandatory academic half-day every week where core topics in intensive care are reviewed. A two year core lecture series has been designed and implemented Based on the objectives of training set out buy the Royal College. The curriculum is continuously reviewed and updated based on trainee and staff feedback.
Multiple different strategies are used to during the academic sessions including didactic sessions, panel discussions, resident led sessions, journal club, and simulation. . There is also hands-on learning with respect to ventilator and dialysis machine parameters and settings. Informal teaching sessions are also held on topics of the residents’ choice.
A record of attendance at the Tuesday sessions is kept. Residents are expected to attend 80% of the Tuesday sessions.
The educational objectives for the University of Toronto Critical Care Medicine training program are based on the CanMEDS 2005 Physician Competency Framework for subspecialty training. The objectives of the program are met during the course of training through the academic half-day lecture series, simulation sessions, journal club, ethics sessions, and clinical rotations. By the end of the training period, the resident will acquire the core competencies required to function as an independent critical care consultant
Elective Specific Goals and Objectives
- the general support, together with any specific antidotes or supportive therapy pertinent to individual intoxicants
- the pharmacology of common intoxicants
- strategies to reduce absorption and enhance elimination (hemodialysis, hemoperfusion)
- Liaise and provide support to health care providers in the management of intoxicated patients
- Develop a care plan with input from toxicologists, emergency and critical care physicians in the management of intoxicated patients
- Follow-up with physicians on the outcome of intoxicated patients
- Effectively work with a variety of health care professionals with varying levels of expertise to coordinate the care of intoxicated patients.
- Learn to work with other allied health professionals during multidisciplinary rounds.
- Learn to coordinate the care of intoxicated patients.
- Learn to manage the care of patients using a variety of resources.
- Develop an understanding of individuals who are at risk for intoxication / poisoning / suicide attempts
- Learn how to coordinate care of patients who are in remote under-serviced locations.
- Act as a resource for physicians and other health care professionals
- Present cases at rounds
- Discuss cases with the toxicologist on call.
- Learn to be an effective resource in the care of patients by providing timely, helpful and accurate information on the care of intoxicated patients.
- Learn how to assess the airway
- Learn how to oxygenate patients using bag / mask ventilation
- Learn how to prepare the airway for intubation
- Learn how to ventilate patients using a laryngeal mask.
- Learn how to secure the airway using direct laryngoscopy, bronchoscopy.
- Learn the pharmacology of induction agents, sedatives, neuromuscular blocking agents.
- Learn methods of venous cannulation
- Demonstrate knowledge of the principles and practice of anesthesia as they apply to patient support during surgery or obstetrics
- Communicate effectively with medical colleagues, nurses, and paramedical personnel in inpatient, outpatient, and operating room environments
- Develop a care plan with input from the staff anesthetist and surgeon.
- Able to coordinate the care of patients who become unstable during surgery
- Demonstrate ability to function in the clinical environment using the full abilities of all team members.
- Act as an effective resource for management strategies in the care of the anaesthetized patient.
As per general objectives.
- Demonstrate knowledge of age related variables in medicine as they apply to neonatal, pediatric, adult and geriatric patient care
- Act as a resource for physicians and other health care professionals
- Present cases at rounds
- Present a care plan based on best practice with the anesthetist on call.
- Learn to be an effective resource in the care of patients by providing timely, helpful and accurate information on the care of surgical patients.
Coronary Care Unit
Upon completion of the rotation, the resident will learn:
- Diagnosis and principles of management of acute coronary syndromes including indications for thrombolysis
- Principles of management of cardiogenic shock. In particular the roles of:
- Vaso-active medication (milrinone, dobutamine, nitroprusside)
- Intra-aortic balloon pump (application, complications of, and troubleshooting)
- Ventricular assist devices
- Cardio-pulmonary bypass, including ECMO therapy
- Management of acute pericarditis
- Management of pericardial tamponade
- Management of stable and unstable arrhythmias
- Ventricular and supra-ventricular tachycardias
- Pacemaker syndromes
- Understand the principles of external and internal cardiac pacing
- Effect of mechanical ventilation on cardiac performance/function.
- Principles of cardiac energetics, metabolism, conduction and contraction/contractility
The following technical skills will be developed:
- Advanced cardiac life support
- Elective cardioversion
- Insertion of a pulmonary arterial catheter
- Insertion of temporary transvenous pacemaker
- Insertion of an intra-aortic balloon pump (optional and under supervision only)
- Act as a consultant for common cardiac conditions including acute coronary syndromes and arrhytmias.
- Develop and communicate a diagnostic and therapeutic plan
- Lead rounds (year 2) and direct care of patients in CCU.
- Work effectively with various cardiac subspecialties (electrophysiology, echocardiography and angiographers)
- Effectively triage patients with cardiac surgeons.
- Understand the operation of the cardiac triage program
- Learn how to triage patients who require advanced cardiac care
- Develop strategies to prevent venous thromboembolism in patients at risk
- Develop strategies to diagnose deep venous thrombosis in critically ill patients
- Develop strategies to diagnose pulmonary embolism in critically ill patients
- Learn how to treat massive pulmonary embolism
- Learn the appropriate application of tests to diagnose pulmonary embolism including contrast CT, V/Q scan, Doppler ultrasound, D-dimers, and venography.
- Learn about complications of anticoagulation.
- Learn about the manifestations and treatment of heparin induced thrombocytopenia
- Learn about the use of heparinoids
- Learn about appropriate use of IVC filters
- Learn about medical and surgical thrombolytic therapies
- Learn how to communicate management strategies to the multidisciplinary ICU team
- Liase with the coagulation laboratory, hematology and various surgical and medical subspecialties
- Participate in a multidisciplinary thrombosis team.
- Collaborate with primary care physicians and teams in the management of patients with suspected or proven thrombosis or complications of anticoagulation
- Learn to efficiently provide timely consultation in critically ill patients
- Learn how to manage and organize a multidisciplinary team
- Advocate for prevention of thromboembolism in high risk patients
- Learn how to critically appraise the literature with respect to diagnostic, therapeutic and studies of prognosis
- Learn to incorporate best evidence into bedside care
- Learn how to negotiate an effective strategy with primary providers who may have concerns about bleeding risks
- Learn how to effectively provide timely and comprehensive consultations
- Learn how blood products are processed and produced
- Learn about indications for blood product transfusion including platelets, packed red blood cells, plasma, cryoprecipitate, activated factor VIIa, and albumin
- Learn about the infectious and noninfectious complications of transfusion
- Learn how to manage acute complications of transfusion including, sepsis, bacteremia, nonhemolytic transfusion reaction, hemolytic transfusion reaction, thrombocytopenia, transfusion related purpura, and consequences of transfusion mismatch
- Learn about the consequences of massive blood transfusion
- Learn the limitations of redblood cell transfusion in critically ill patients
- Learn about the use of erythropoietin in critically ill patients
- Learn about common coagulopathies in critically ill patients
- Learn how to communicate with primary care physicians and advise on strategies to deal with acute blood loss, coagulopathies and complications of transfusion
- Learn to liase with Canadian Blood Services
- Learn to liase with the hospital’s blood bank
- Learn how to obtain consent for blood transfusion
- Learn to work with a multidisciplinary team comprised of hematologists, transfusion medicine, technicians and the Canadian Blood Services
- Learn how the Canadian Blood Services operates
- Learn how to improve patient safety as it relates to blood transfusion
- Learn how to minimize acute and chronic transfusion reactions
- Learn about legislation as it relates to transfusion of blood products and informed consent
- Learn about blood substitutes for certain religious groups
- Learn how to apply best evidence in the care of the acutely bleeding or coagulopathic patient
- Learn how to work with primary care physicians to provide timely and effective consultation
- Learn how to resolve conflict when there is disagreement between physicians as it relates to the transfusion of blood products
- Learn to manage the initial phase and secondary phase following an acute burn injury
- Learn to manage a patient with an airway injury following a burn
- Learn to recognize and manage acute carbon monoxide and cyanide poisoning
- Learn the various thicknesses of burn and their implication for acute management
- Learn about the airway complications of thermal injury
- Learn about management of the burn patient with MSOF
- Learn about the immunological consequences of burn injury
- Learn about the septic complications of acute burn injury
- Learn how to manage pain the an acutely burned patient
- Learn how to communicate with families of an acutely burned patient
- Learn how to communicate and effective and comprehensive care plan to a multidisciplinary team during bedside and ward rounds
- Learn how to work in a multidisciplinary environment
- Learn how to treat a patient a patient with an acute burn based on physiological principles and best evidence
- Learn how to manage acute pleural space problems including empyema, and pneumothorax
- Learn how to manage patients with acute lung abscess
- Learn about the complications following thoracotomy
- Learn how to manage broncho-pleural fistulae
- Learn about the complications and principles of managing patients after esophagectomy
- Learn about the classification and management of transudative vs. exudative effusions.
Core Competency skills
- Tube Thoracostomy
- Flexible bronchoscopy
- Rigid bronchoscopy
- Percutaneous tracheotomy
The goals and objectives for this elective needs to be discussed with the supervisor and program director and should be stated in the terms of the canMEDs format.
- Learn how to formulate a hypothesis
- Learn how to formulate a research plan
- Learn about the background of the specific topic and research question
- Demonstrate that you have prepared a thorough background research and summary of the current state of knowledge
- Prepare a research proposal
- Prepare a formal manuscript
- Prepare an abstract
- Present at the CCM day in research
- Learn to work with a multidisciplinary team in the research group (technicians, study coordinators, statisticians, ethicists)
- Learn how organize your time to complete the research study
- Learn how to develop a research budget
- Learn about patient safety in studies involving research subjects
- Learn about the role of a data safety monitoring board
- Learn how to conduct a research study using human subjects according to ethical standards
- Learn how to submit an ethics proposal
- Learn about the proper way to conduct studies using animal models, including anaesthesia, analgesia, instrumentation, procedures, and ensuring the access to food and drink and humane euthanasia
- Learn about study design
- Learn about basic summary and comparative statistics.
(the statistical knowledge will in part depend upon the research question and methodology)
- Learn how to develop a research question
- Learn how to critically appraise prior research as it pertains to your research question
- Learn how to critically appraise your own research methods
- Demonstrate the ability to complete tasks