Fellows contribute to inpatient care by participating in rounds, providing information about patient care and advising the resident staff.
Specific patient care responsibilities include:
- Performing a hand/upper extremity exam on patients admitted through the emergency room or through outpatient or private offices in which the fellows participate in their surgical management.
- Making daily rounds on hand/upper extremity patients
- Serving as a resource of experience and knowledge to the resident staff
- Writing orders as appropriate
- Evaluating consults and aiding the resident and attending staff
The presence of the fellows will augment, not supplant, resident responsibility. The clinical care of inpatients is the primary responsibility of the attending and resident staff. Clinic hours, as mandated by the RRC, include 49 weeks in training.
Inpatients are assigned to one of four teams. Each team is comprised of:
- Three attendings
- Chief resident (PGY-5)
- PGY-3 or PGY-4 resident
- Junior resident (PGY-2)
- One or two PGY-1, -2, or -3 residents from general surgery, emergency medicine or family practice
Supervision and Administration
- Fellows participate in rounds, provide information regarding patient care, and advise the resident staff.
- Team administration is directed by the chief resident who utilizes the fellows as a clinical resource.
- Final decisions regarding patient care are at the attending level.
- Supervision is by direct observation during daily ward rounds. The fellows and one or more residents are expected to round with an attending on all patients.
- Inpatient consults are assigned by the administrative chief to an appropriate attending.
- Emergent upper extremity consults are seen by the first available physician, resident, fellow, or attending.
- Semi-emergent upper extremity consults will be assigned by the chief resident to one member of the resident staff and the fellow will be notified by the secretary as to the name and location of the patient. The resident and fellow, unless unavoidable conflicts exist, will evaluate the patient, establish a diagnosis and differential diagnosis, and outline a treatment plan. The patient will then be presented on rounds to the attending staff who will evaluate this patient and discuss diagnostic alternatives and management options.
Conferences and Didactics
Formal training in hand and upper extremity is an integral component of the current orthopaedic training program.
The weekly hand conference, held 46 times a year, is the central educational component of the fellowship.
The hand conference is divided into three components:
- 14 hours of didactic lectures
- 22 hours of Socratic case discussions
- 10 hours of anatomy
Dissection/prosections use embalmed and fresh-frozen extremities to highlight the anatomy component of this conference. Basic science residents perform these dissections prior to the conference, and then present the prosection to the group with a faculty advisor. Hand fellows are expected to assist the basic science residents with their dissections.
The format consists of a 30- to 40-minute presentation, where a fellow is responsible for overseeing the anatomy dissection with the basic science resident. After the presentation, the fellow leads a 20- to 30-minute discussion of relevant OITE or OSAE questions. The fellow is also responsible for assigning brief journal articles from the prepared syllabus.
A fellow typically presents two or three topics each year.
Formal Pre-Operative Conferences
Formal pre-operative conferences are held once per week on Monday from 7 am to 9 am. Cases for the week are reviewed. The fellow and resident attending each present one or 2 cases that have been posted for at least one week and describe the clinical history, physical exam, and radiographic findings, the differential diagnosis, and alternative management options, indications for surgery, surgical options, post-operative care, and expected outcome. The remainder of the cases will be presented by the attending or staff and follow similar guidelines.
Orthopaedic Complications Conference (Morbidity and Mortality)
The fellows attend orthopaedic complications conference (Morbidity and Mortality) once per month and are expected to discuss upper extremity morbidity or complications. The hand fellows attend Orthopaedic Grand Rounds and present upper extremity cases when assigned by the administrative chief resident.
Musculoskeletal Pathology Conference
The fellows attend bi-weekly Musculoskeletal Pathology Conference and are expected to present one or 2 conferences per year as assigned by the administrative chief and our musculoskeletal oncology faculty. The fellows attend trauma conference as appropriate.
Hand Journal Club
Hand fellows are expected to attend and participate in a monthly journal club. The chief resident assigns upper extremity articles to each fellow. Selected articles are chosen from the Journal of Hand Surgery (American and British volumes) and the Journal of Microsurgery. Coordination of the Hand Journal Club will be the primary responsibility of the fellows.
In addition to the existing weekly Hand Conference schedule, the hand fellows participate in Tumor Conference, and basic science and upper extremity topics covered in the Pediatric Conference. The existing monthly journal club will continue to include upper extremity topics. The hand fellows are expected to attend and participate. Upper extremity articles are assigned to the fellow by the chief resident for presentation and discussion. This conference (optional for resident staff) emphasizes selected articles from the Journal of Hand Surgery (American and British volumes) and the Journal of Microsurgery. Articles for discussion are selected by Dr. Koman and the fellow and discussed by the fellow, residents, and hand faculty. Coordination of the Hand Journal Club will be the primary responsibility of the fellow.
Hand fellows are encouraged to develop and pursue independent projects, as well as participate in other ongoing research. Support offered by the program includes time, space, computer/statistical aid, equipment, supplies, trained orthopaedic technicians, and direct supervision by Beth Smith, MD, and faculty.
Research Focus and Meeting
Hand fellows meet weekly with the entire hand team to review the core curriculum and cases for the upcoming week. This meeting also provides a focus for research activities. Participation in this meeting is expected in addition to the eight hours of basic science time per week.
Fellows are expected to participate in a presentable research project for the North Carolina/Virginia hand fellowship research symposium, as well as create a publishable paper after the completion of the fellowship.
Fellows are expected to present their research at the annual alumni meeting in June or July and have a publication-ready project by the end of the fellowship.
Fellows are expected to participate in:
- Anatomic dissections
- Clinical research
- Basic research
The department recognizes that prime-time hours (9 am–5 pm) should be kept free from patient care responsibilities (as much as possible) in order to perform meaningful research.
Fellows are evaluated on both their activities and progress. Throughout the fellowship, you’ll keep records detailing clinical experience, educational activities and research exposure. These are reviewed with you on a monthly basis, at which time you’ll be given feedback regarding your performance, as well as an opportunity to critique your educational experience.
These evaluations are reviewed by the Education Committee, the director of the hand fellowship and the director of the orthopaedic program on a quarterly basis.