Iowa Cataract Surgery Training Plan

Summary  At the University of Iowa we have a developed a training plan that allows for a safe transition to the OR with increasing responsibility as residents progress through our program. 

First year – Beginner

Expectations following the first year or at “Beginner Stage”                  

• know accepted names of all instruments in VA cataract tray
• describe all steps of cataract surgery
• describe common complications of cataract surgery
• demonstrate ability to fold and insert IOL into capsular bag
• demonstrate ability to prep and drape eye
• demonstrate ability to drive operating microscope
• demonstrate ability to place a single suture
• demonstrate ability to remove OVD
• demonstrate ability to perform Yag capsulotomy
• manage routine cataract patients postoperatively
• describe findings of CME on OCT and FFA
• describe common complications of Yag capsulotomy

Resources to develop these skills

Wet Lab fully equipped, dedicated facility at VAMC work in wet lab w/cadaver or pig eyes
EyeSi virtual simulator

eBook http://medrounds.org/cataract-surgery-greenhorns or down load itunes

EyeRounds tutorial on instruments at VA and UIHC     Http://eyerounds.org developed by Rob Dinn, MD

ipod Greenhorn Series, eg: ICCE, ECCE, prep, RB, AEL, microscope, my first cataract

VA rotation – Wed and Thursday with Oetting Backing into cases (Senior Resident does initial part of the case, then 1^st yr slowly does more and more of “back” of case; eg: wk 1 1^st year preps patient and folds IOL, wk 2 1^styear preps, folds IOL, injects IOL, removes OVD, later  1^st year preps, removes cortical material, injects IOL, rarely 1^st yr will do phacoemulsification

VA rotation – Tuesday AM assist during Dr Greenlee’s cases learn instruments, eye prep and techniques of a good assistant

UIHC Dr Kutzbach -- Monday AM backing into cases

M&M Conf Practice Based Learning every 10 weeks

Phaco Course Madison Wisconsin (UW, UI, MCW residents) advanced lectures ½ day/wet lab ½ day

Expectation	Assessment	Resources
know accepted names of all instruments in VA cataract tray	Demonstrate in OR	Ipod Greenhorns Eyerounds.org
describe all steps of cataract surgery	Oral	Greenhorns
describe common complications of cataract surgery	Oral	Greenhorns
demonstrate ability to fold and insert IOL into capsular bag	Demonstrate in OR	Wet Lab ipod Greenhorns
demonstrate ability to prep and drape eye	Demonstrate in OR	ipod Greenhorns
demonstrate ability to drive operating microscope	Demonstrate in OR	Wet Lab ipod Greenhorns
demonstrate ability to place a single suture	Demonstrate in OR/wet lab	Wet Lab
demonstrate ability to remove OVD	Demonstrate in OR	Wet Lab
demonstrate ability to perform Yag capsulotomy	Demonstrate in clinic
manage routine cataract patients postoperatively	Demonstrate in clinic	Greenhorns
describe findings of CME on OCT/FFA	Oral
describe common complications of Yag capsulotomy	Oral

Second Year – Advanced Beginner

           

Expectations following the second year or at “Advanced Beginner Stage”

• know name of all instruments on all VA eye trays
• consent patient for routine cataract surgery
• perform 5 uncomplicated phaco cases (attending may assist with 2^nd hand) < 45min
• describe steps to convert to ECCE
• describe technique of anterior vitrectomy
• demonstrate ability to perform A scan for AEL
• demonstrate ability to place multiple sutures efficiently
• demonstrate ability to use capsular dye

Resources to develop these skills

Wet Lab fully equipped, dedicated facility at VAMC work in wet lab w/cadaver or pig

eBook http://medrounds.org/cataract-surgery-greenhorns or down load itunes

EyeRounds tutorial on instruments at VA and UIHC Http://eyerounds.org developed by Rob Dinn, MD

ipod Greenhorn Series, eg: making a groove, ICCE, ECCE, prep, RB, AEL, microscope, My First Cataract

Observed Professional Communication Competency Consent feedback on EPIC

OR            formative feedback form for portfolio

VA rotation – Wed and Friday AM observe 3^rdyear 1^st case

VA rotation – Thursday AM – Dr Oetting 1-3 cases Oetting will help with second instrument at first usually with retrobulbar anesthesia all cases video taped – review progress/complications

UIHC rotation – Tuesday – Dr Johnson transition to topical anesthesia deliberate practice on capsulorhexis.  video formative feedback

M&M Conf Practice Based Learning Competency every 10

Phaco Course Madison Wisconsin (UW, UI, MCW residents) advanced lectures ½ day/wet lab ½ day

Expectation	Assessment	Resources
know name of all instruments on all VA eye trays	Oral	ipod EyeRounds.org
consent patient for routine cataract surgery	Jan Full	ipod
perform 5 uncomplicated phaco cases < 45min	Formative feedback forms	Ipod facebook
describe steps to convert to ECCE	Oral	Greenhorns facebook
describe technique of anterior vitrectomy	Oral	Greenhorns facebook
demonstrate ability to perform IOL Master  for AEL	Observe in clinic	Clinic staff
demonstrate ability to place multiple sutures efficiently	Observe in OR	Wet Lab
demonstrate ability to use capsular dye	Observe in OR	Greenhorns facebook

Third Year -- Proficient

Expectations following the third year or at “Proficient Stage”

• understand IOL selection
• consent patient for complex cataract surgery (eg CTR, ICG)
• perform 5 phaco cases with 2 hand < 30min
• demonstrate or deeply understand conversion to ECCE
• demonstrate or deeply understand anterior vitrectomy
• demonstrate or understand sulcus IOL placement
• understand phacoemulsification machine settings
• understand OVD selection
• demonstrate ability to use iris hooks 

Exceptional samples of behavior rarely seen during third year “Expert Stage”

• demonstrate ability to use McCannell suture
• demonstrate ability to use CTR         
• demonstrate ability to do very efficient cataract surgery < 15 minutes
• demonstrate ability to use phaco chop techniques
• staff first years during portions of cataract surgery

 Resources to develop these skills

Wet Lab fully equipped, dedicated facility at VAMC work in wet lab w/cadaver or pig eyes

eBook http://medrounds.org/cataract-surgery-greenhorns

http://facebook.com/cataract.surgery

http://cataractsurgeryforgreenhorns.blogspot.com

EyeRounds tutorial on instruments at VA and UIHC Http://eyerounds.orgHttp://eyerounds.org developed by Rob Dinn, MD

Facebook, ipod  eg: transition to phacochop, phaco chop with Ozil,

OR            learning with formative feedback form for portfolio

VA rotation – Wednesday AM Oetting,, 4-10 cases, develop ability to use second instrument, develop skills to do topical cases, transition to chopping technique

UIHC Comprehensive rotation Thursday Kitzmann 2-5 cases emphasis on chopping and efficiency

UIHC Comprehensive rotation Friday Oetting 2-5 cases emphasis on complex cases and efficiency

M&M Conf Practice Based Learning Competency lead conference every 10 weeks open discussion of complicated cases at UIHC and VAMC UI during rounds

           

Expectation	Assessment	Resources
understand IOL selection	Oral	Greenhorns
consent patient for complex cataract surgery (eg CTR, ICG)	Oral
perform 5 phaco cases with 2 hand < 30min	Formative Feedback Form
demonstrate or deeply understand conversion to ECCE	Oral	Greenhorns DVD
demonstrate or deeply understand anterior vitrectomy	Oral	Greenhorns DVD
demonstrate or understand sulcus IOL placement	Oral	Greenhorns DVD
understand phacoemulsification machine settings	Oral	Greenhorns DVD
understand OVD selection	Oral	Greenhorns DVD
demonstrate ability to use iris hooks	Observe in OR	Greenhorns DVD

                        Summary of Cataract Competency Thread

Dreyfus Stege	Level	Expected Samples of Behavior For this level	Typical  rotation at this level	% grads at this level	Resources to Grow beyond this level
Novice	Starting	Desire to learn	n/a		Books video observe
	assistant surgeon	demonstrate sterile technique know all instruments in tray know all steps of cataract surgery demonstrate prep and drape demonstrate IOL fold demonstrate RB injection	VA 1st yr		Books wet lab video observe
Beginner	wet lab surgeon	demonstrate microscope use pig/cadaver eye with faculty	VA 1st yr		wet lab video back into cases
	neophyte surgeon	demonstrate suture technique demonstrate IOL placement demonstrate use of I/A device	VA 1st yr		wet lab video back into cases
Advanced Beginner	Basic cataract surgeon	demonstrate 5 cases < 45 min know steps to convert to ECCE know steps for vitreous loss demonstrate use of capsule dye demonstrate effective consent	VA 2nd  yr	100%	wet lab video develop non-dominant hand
	assistant topical surgeon	demonstrate capsulorhexis during topical case assist efficient cataract surgeon	UI 2nd yr	100%	video
Proficient	two handed surgeon	demonstrate 5 cases < 30 min using both hands demonstrate topical cases	VA 3rd yr	95%	video
Expert	advanced surgeon	demonstrate the use of small pupil techniques demonstrate the use of CTR demonstrate chopping techniques demonstrate IOL suturing techniques	VA 3rd yr DM 3rd yr UI 3rd yr	60%	video
	efficient surgeon	demonstrate 5 cases < 15 min	VA 3rd yr DM 3rd yr UI 3rd yr	10%	video

                                                                                                                                                                                                           

THE FIX IS IN - The Miller Firm LLC

Hear Ye! Hear Ye! for all those injured or killed by Seroquel! it's settled Suckers

 THE FIX IS IN  - The Miller Firm LLC says they have magically reached settlement threshold, & are presenting results to AstraZeneca in an attempt to cash in on the Seroquel Litigation

In the continuing saga of "How the Seroquel Settlement World Turns" The Miller Firm Seroquel Update Recording today (*800* 882 -2525) announced they have reached the required number of settlement packets to move forward with asking AstraZeneca to release funds. 

Of course The Miller Firm does not say how many settlement approval packets they have actually received, or how many clients they have dumped to the streets in pursuing this magical threshold mark of 93% approval.

 This is all very secretive stuff that The Miller isn't sharing with their Clients or anyone else except AZ (you know the clients, injured parties, those people they are supposedly working for). Though one must seriously & reasonably wonder out loud what's really going on here; especially when a firm has been sitting at a 40% rejection rate for a year, and then in three weeks time somehow pulls a settlement agreement rabbit out of thier hat so to speak. 

This is why interested parties and clients are asking & calling for an investigation by Federal authorities @ the Department of Justice and the Court. Not only does the documented actions of The Miller Firm not passing the ethical & professional smell test....shall we start throwing around nasty words like "Fraud"? "Racketeering"? "Conspiracy"? or other related pleasantries to garner attention to the Injured Parties plight....The time has now come to have this secretive & unsavory curtain pulled back for all to see...

We know that The Miller Firm LLC and non-participant co-counsel have been tooting the settlement horn with their cheerleader buddies at the Garretson Resolution Group & AstraZeneca for over a year now. From the clients I've had correspondence with...The Miller Firm has quashed any & all conversation, inquiry, or mention of further negotiations or any chance of preparing their cases further for trial. 

There are so many questions, yet The Miller Firm & co-counsel refuse to answer any and all questions that don't directly refer to getting this settlement approved, or getting that settlement cash in their pockets.  

This blog has chronicled this secretive, often threatening, and closed door  process for almost a year now....Injured parties that are refusing this insulting & unfair offer are no closer to receiving legitimate counsel, a court hearing before a jury of their peers, or finding even the most remote form of justice now, anymore than they were then. 

This is a testament to how truly perverted and corrupted our legal system, the law profession, and the courts have become. It seems or appears that only the wealthy, elite, politically connected, corrupted, and those recognized into the small members only club receive the treasured promise of the courts and justice in America...The rest receive what has been written on the pages of this blog....it's simply insult added to injury....

I invite you the reader to go back & read through this blog's journey over the past many mouths & ask yourself this question; Have injured parties in the Seroquel litigation received anything that can be taken as, would be construed as, or closely resembling justice from the courts, media, their own legal representation, and most of all....from the AstraZeneca corporation that with forethought and malice caused them grave injury or death with the drug Seroquel? 

as they say....this ain't over until the last Seroquel induced fat lady sings.... 

But then again...will injured parties even be dealing with AstraZeneca six months or a year down the road...or some other huge corporate entity?
-----------------------------------------

from MM&M - medical, marketing & media

AstraZeneca's patent plight points toward takeover: analyst

Deborah Weinstein

March 13, 2012

 Despite a brimming pipeline touted by execs earlier this year, storm clouds are gathering for AstraZeneca, and the best way to weather them is through a takeover, says one analyst.
If it wants to deliver results, the UK drugmaker's dwindling set of options really boils down to one: take over a company with a pipeline that will keep it afloat, wrote Tim Anderson of Sanford Bernstein.

In a note titled, "Something's Gotta Give. But When & Why?" Anderson writes of a "left for dead" attitude by many investors towards the company. “AZN faces a prolonged, multi-year patent cliff that gives it among the steepest revenue and EPS declines of the different US and European companies we cover,” Anderson noted, referring to a slew of patent expirations that start in 2012 and run through the next the next four years. Among those aging out this year are anti-psychotic Seroquel and blood pressure drug Atacand. Seroquel IR and XR brought in over $6 billion in sales for the company last year, and Atacand brought in almost $2 billion. Blockbuster Crestor ($6.6 billion in sales last year), already generic in some European markets and facing a threat from off-patent Lipitor in the US, is scheduled to lose US exclusivity in 2016.

click on the link above to read the rest of the article....