Level: PGY-4

Service: Colorectal Surgery 

Supervision: PGY-4 → Attending

Jennifer S. Beaty, MD
Alan G. Thorson, MD
Garnet J. Blatchford, MD
Carlos A. Ternent, MD
M. Shashidharan, MD

All management decisions will be discussed with the faculty. 

Duty Hours:

Hours are to be logged into New Innovations on a weekly basis and will be reviewed weekly by the Program Director for ACGME violations and reviewed weekly for delinquencies by the Program Coordinator. Over a four week period; you will not average more than 80 hours a work week, you will have one day in seven free of clinical duty, in-house call will be no more frequent than one in three nights, you should receive 10 hours free between all duty periods and after in-house call and you will not be on duty for more than 24 consecutive hours with an additional 4 hours for transitional duties only.  If you are assigned more hours than mentioned heretofore or have patient care duties that are extending you beyond these limits, it is your responsibility to notify your supervising resident or faculty so arrangements can be made to relieve you. 

Educational Activities:

  1. Recommended Reading 
    • ASCRS Textbook of Colon, Rectal and Anal Surgery
    • Nivatvong’s Textbook of Colon, Rectal and Anal Surgery
    • Schwartz's Principles of Surgery
    • Cameron’s Current Surgical Therapy
    •  SCORE curriculum modules
  2. Conferences
    • Wednesday Resident Educational Curriculum
    • Tuesday Colorectal Surgery Conference,  7-9am 

Competency Based Performance Objectives:

Patient Care:

Goal: Demonstrate proficiency in diagnosis, preparation, operative treatment, and total management of the uncomplicated colon, rectal and anal patient, including long-term follow-up care

Objective: The resident will be able to: 

  1. Demonstrate the capability for independent function in all aspects of basic colon, rectal and anal cancer patient management, including palliative care planning
  2. Independently evaluate a new colon, rectal or anal cancer patient through history and physical examination, ordering appropriate and cost-effective tests such as ultrasound, endoscopy, CT scans, PET scans and MRIs.
  3. Prescribe various types of adjuvant and neoadjuvant therapies such as: Chemotherapy  and Radiation therapy
  4. Outline an appropriate follow-up schedule for patients who have undergone:
    • Treatment of colon, rectal and anal cancers with curative intent
    • Polypectomies during endoscopy or during segmental resection
  5. Stage specific neoplasms clinically and pathologically using the TNM system
  6. Prepare an operative plan for treatment of malignant diseases of colon, rectum and anus.
  7. Perform colostomies, colostomy closures, and bowel anastomoses of all types
  8. Prepare and defend the pre-operative assessment plan for the elderly patient in preparation for colorectal resection of all types, including ostomy planning
  9. Demonstrate proficiency in interpretation of endoscopic ultrasonography of rectum and anus.
  10. Perform, with appropriate supervision, major resections of the colon and rectum.
  11. Assume responsibility for managing the psychosocial aspects of neoplastic diseases
  12. Utilize appropriate social agencies and support groups in cancer patient management.
  13. Demonstrate proficiency in colonoscopy and adjunct procedures of snare polypectomy and tattooing.
    • Articulate screening and surveillance strategies for colon and rectal cancer prevention
  14. Assume teaching responsibilities for medical students as assigned
  15. Participate in a multidisciplinary tumor boards
  16.  Formulate a diagnostic work-up and treatment plan for most common uncomplicated anorectal problems:
    • internal hemorrhoids
    • external hemorrhoids
    • abscess
    • fistula
    •  fissure
    • pruritus ani
    •  anal pain
    • condyloma
    • rectal bleeding
  17. Demonstrate proficiency in common anorectal surgical procedures:
    • Internal sphincterotomy
    • Seton placement
    • 2ndstage fistulotomy
    • Banding of hemorrhoids in the office setting
    • Operative hemorrhoidectomy for acute and chronic hemorrhoid disease
    • Abscess drainage under local and in the operative setting
    • Condyloma management in office and operative setting
  18. Formulate a diagnostic work-up and treatment plan for fecal incontinence and constipation.
    • Demonstrate familiarity with anorectal physiology studies (ultrasound, ARM, EMG, pudendal nerves, proctograms, colon transit times)
    • Have awareness of treatment options for fecal incontinence (dietary modifications, physical therapy, sphincteroplasty, Solesta injections, sacral nerve stimulators, SECCA)
  19. Demonstrate familiarity with Ulcerative Colitis and Crohn’s patient disease processes and formulate medical and surgical management strategies.
  20. Formulate a diagnostic and treatment plan for patients with acute and chronic diverticulitis. 

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate understanding of the biology, pathology, diagnosis, treatment, and prognosis of neoplastic diseases, understand surgical options of curative and palliative care for colorectal and anal cancer patients, and understand the network of community resources and their functions, available to patients at end of life.  Demonstrate knowledge of the anatomy, physiology, and pathophysiology of the colon, rectum and anus, demonstrate the ability to surgically manage benign and malignant diseases of the colon, rectum and anus, and understand the advancements of minimally invasive surgery in resections of the colon and rectum

Objectives: The resident will be able to:

  1. Apply clinical screening for common malignancies involving the colon, rectum and anus. Recognize typical presentations and clinical manifestations for different types of neoplasms.
  2. Describe the stimuli for and the biologic events in angiogenesis and the potential therapeutic implications thereof
  3. Discuss the known facts relative to tumor suppressive genes and the implications of mutations.
  4. Stage specific neoplasms both clinically and pathologically, including the tumor, nodes, and metastasis system (TNM).
  5. Relate tumor staging to prognosis.
  6. Describe differences in presentation, treatment, and outcomes for malignancy in older patients.
  7. Compare each applicable treatment modality to the prognosis for tumors within the scope of general surgery.
  8. Apply post-treatment screening/surveillance for common malignancies.
  9. Discuss the known facts relative to tumor recurrence after local resection of a primary lesion of the colon, rectum and anus with regard to survival
  10. Identify margins of resection and how this relates to local recurrence
  11. Explain the fundamental principles of radiation oncology and detail its application as primary, neoadjuvant or adjuvant therapy for the treatment of selected lesions.
  12. Summarize the indications and appropriate modalities for adjuvant therapy within the scope of general surgery, including chemotherapy, radiation therapy, immunotherapy, and gene therapy.
  13. Demonstrate a working knowledge of prior research milestones, current research efforts, and cancer research methodology.
  14. Describe the characteristics, diagnosis, and therapy of common diseases of the anorectum:
    • internal hemorrhoids
      • external hemorrhoids
      • abscess
      • fistula (anorectal and rectovaginal)
      •  fissure
      • pruritus ani
      •  anal pain
      • condyloma
      • rectal bleeding
      • fecal incontinence
  15. Describe the basic issues in the staging and treatment of metastatic colorectal cancer, including the role of:
    • Chemotherapy
    • Radiation therapy
    • Diversion of stool
    • Use of stents
    • Resection of primary tumor versus leaving primary in situ
  16. Formulate plans for basic patient care, including pre-, intra-, and post-operative care for colorectal and anal procedures for:
    • Crohn’s disease
    • Ulcerative Colitis
    • Familial Adenomatous Polyposis
    • HNPCC
    • Infectious Colitis
    • Perforated colon/rectum
    • Diverticular disease
    • Fistulas
    • Hemorrhoids
    • Fissures
    • Condyloma
    • Fecal Incontinence
    • Constipation
    • Rectal Prolapse
    • Benign Polyps
    • Abscesses
  17. Describe the normal anatomy, histology, physiology, and pertinent biochemistry of the following organs:
    • Small intestine
    • Colon
    • Rectum
    • Anus
  18. Learn relevant detailed physiology.
    • Colonic motility
    • Defecation
    • Normal stool components and changes associated with resections, ileostomy, colostomy
  19. Management of the postoperative patient.
    • Intra-/postoperative fluid status
    • Stoma management
    • Pain control
    • Enteral nutrition
    • Coagulation abnormalities
    • Glucose and electrolyte abnormalities
  20. Learn to recognize and treat common post-operative complications:
    • Urinary retention
    • Wound infection
    • Anastomotic leak
    • Pelvic sepsis 

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for colon, rectal and anal procedures

Objectives: The resident will demonstrate the ability to obtain informed consent, outlining the risks and benefits 

Goal: Communicate effectively to discharge patients after surgery.

Objectives: The resident will demonstrate the ability to instruct patients regarding monitoring for colon, rectal and anal procedure post-operative complications: 

Goal: Communicate effectively as a member of the healthcare team.

Objectives: The resident will demonstrate the ability to communicate effectively by:

  1. Providing appropriate check out when handing patients to another team member
  2. Requesting consults from other services with appropriate information
  3. Dictating reports in a timely fashion 

Professionalism:

Goal: Maintain patient confidentiality

Objectives: The resident will demonstrate

  1. The ability to protect health-related patient information per HIPAA compliance
  2. List and be aware of sites in the hospital and clinic where loss of privacy for the patient may occur 

Goal: Maintain appropriate professional relationships

Objectives: The resident will demonstrate professional interactions with:

  1. Medical students
  2. Nursing and support staff
  3. Supervising faculty
  4. Consulting residents
  5. Physician peers
  6. Patients and their families

Practice-Based Learning and Improvement

Goal: Identify personal and practice improvement strategies

Objective: The resident will demonstrate:

  1. Receptiveness to faculty instruction and feedback
  2. Ability to use medical information with the ability to access information through traditional and online sources to support their educational experience

Goal: Use medical evidence to evaluate colon, rectal and anal surgical practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding colon, rectal and anal pathology

Systems-Based Practice

Goal: Provide safe patient care

Objective: The resident will:

  1. Attend Crew Resource Management courses as required by the hospital
  2. Follow recommended protocols in the OR for patient safety
  3. Demonstrate compliance with Medical Center policy for surgical site identification
  4. Demonstrate compliance with Medical Center policy for patient identification

Duties/Responsibilities:

  1. Serve as PGY-4 on the Colon and Rectal Surgery service with the Colon and Rectal Surgery Resident serving as Chief of Service
  2. Appropriate, professional supervision of student teaching in light of educational goals
  3. Attend clinic as assigned
  4. Manage OR patients with supervision
  5. Assist with consultations to the colon and rectal surgery service as assigned by the Attending
  6. Round on post surgical service patient's as instructed.
  7. Attend educational conferences
  8. Complete surgical case logs
  9. Dictate in a timely fashion
  10. Take home call as assigned

Evaluation:

  1. Performance feedback will be given to the resident as appropriate for educational events and mid-term progress will be discussed.
  2. Global evaluation will be performed by the colorectal surgery attending physicians at the completion of each rotation. Surgical case logs will be evaluated for the appropriate number and breadth of procedures and will be present in the resident's portfolio to be reviewed at the Program Evaluation meeting held twice yearly.
  3. At the completion of this rotation, the resident is required to complete a rotation evaluation form assessing the quality of the rotation. The resident should also address the teaching undertaken by the attending physicians on the rotation at the conclusion of this rotation.

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