Specific Educational Goals and Education

Level: PGY-1

Service: UH3

Supervision: PGY-1 → PGY-2 → Chief Resident → Attending

All management decisions will be discussed with the senior residents and faculty.

Duty Hours:

Hours are to be logged into GMEOne 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 30 consecutive hours. 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
    1. Schwartzs Principles of Surgery
    2. SCORE curriculum modules 
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: Demonstrate proficiency in diagnosis, preparation, operative treatment, and total management of the cancer patient, including long-term follow-up care. Demonstrate ability to surgically manage diseases of the breast.

Objective: The resident will be able to:

  1. Perform a complete history and physical examination on patients with cancer.
  2. Take an appropriate history to evaluate breast patients to include:
    1. Pertinent risk factors
    2. Previous history of breast problems
    3. Current breast symptoms
  3. Demonstrate an increasing level of skill in the physical examination of the breast, including recognition of the range of variation in the normal breast.
  4. Formulate an appropriate differential cancer diagnosis, and record an independent, written diagnosis for each cancer patient assigned.
  5. Perform simple procedures such as:
    1. Diagnostic fine-needle aspiration of cysts
    2. Drainage of simple breast abscesses
    3. Core needle biopsy of breast masses
    4. Open biopsy of superficial masses
  6. Identify common lesions such as fibroadenomas, cysts, mastitis, and cancer.
  7. Interpret signs suspicious for malignancy on mammogram such as stellate masses or suspicious microcalcifications.
  8. Perform open breast biopsies and other operative procedures such as simple mastectomy and excision of intraductal papillomas, under direct supervision.
  9. Demonstrate the ability to satisfactorily orient the surgical specimen for pathologic examination.
  10. Determine the indications and special requirements for tissue processing for estrogen and progesterone receptors.
  11. Educate patients to perform breast self-examination.
  12. Demonstrate familiarity with male breast problems, including gynecomastia and male breast cancer.
    1. Discuss risk factors
    2. Outline appropriate work-up and management
  13. Excise benign lesions of skin, dermal appendages, and breast. Demonstrate proper wound care and follow-up management.
  14. Excise skin cancers, demonstrating proper wound margins and appropriate wound closure and follow-up management.
  15. Manage colostomies and ileostomies.
  16. Design an appropriate nutritional support program for a cancer patient both pre- and post-operatively.
  17. First assist on oncologic procedures.
  18. Perform lymph node biopsies, breast biopsies, and procedures of similar magnitude.
  19. Perform feeding gastrostomies and tube jejunostomies.
  20. Perform endoscopic procedures.
  21. Complete a preliminary evaluation of patients suspected of having endocrine disease to include:
    1. Focused history
    2. Family history
    3. Physical examination
    4. Appropriate relevant diagnostic studies
  22. Participate in the pre- and post-operative care of patients undergoing endocrine surgery.
  23. Perform a detailed evaluation of patients with suspected endocrine disease.
  24. Manage the pre- and post-operative care of patients with endocrine disease, under supervision.
  25. Observe and assist in surgery of the thyroid, parathyroid and adrenal glands, as well as those of the pancreas.

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 cancer patients, and understand the network of community resources and their functions, available to patients at end of life. Demonstrate ability to surgically manage diseases of the breast.

Objectives: The resident will be able to:

  1. Discuss frequency/death rates of the top five benign and malignant neoplasms in men, women, and children in the United States .
  2. Describe trends of increasing, decreasing, and high incidence for certain solid neoplasms.
  3. Explain the implications of the heterogeneous cellular makeup of most solid neoplasms with reference to clinical behavior and response to adjuvant treatment.
  4. Discuss the mechanisms of cellular apoptosis and the potential feasibility for therapeutic applications.
  5. Identify genetic factors associated with neoplastic disease in regard to known proto-oncogenes.
  6. Define current theories of carcinogenesis.
  7. Summarize the tenets of tumor biology, including the biochemical events of invasion and metastasis; describe the natural history of these lesions.
  8. Identify and differentiate between the diagnostic features of benign versus malignant neoplasms (gross and microscopic).
  9. Predict patterns of presentation of malignant neoplasms.
  10. Describe the characteristics of the various staging systems and explain their use in evaluating malignant neoplasms.
  11. Outline the appropriate usage of tumor markers, tumor excretory metabolites, and diagnostic cytologic techniques.
  12. Describe the principles of surgical technique for operative procedures designed for cure of malignant diseases and their application to endoscopic operative techniques.
  13. Summarize the nutritional requirements for cancer patients, and describe how they differ from those recommended for a healthy patient.
  14. Describe indications for curative versus palliative treatment, and formulate therapeutic plans for each approach.
  15. Outline the status of the current predominant investigative work in cancer immunotherapy.
  16. Explain the rationale for the use of heat shock proteins in conjunction with immunology.
  17. Summarize current techniques of genetic screening for cancer.
  18. Describe the biologic rationale, mechanisms, and current status of gene therapy for malignancy.
  19. Describe the enzymatic determinants of prognosis for epithelial derived cancers and their biologic sources.
  20. Discuss the economic and psychosocial issues associated with malignant disease, and analyze how they affect the management of patients with cancer, including:
    1. Ethics of cancer management
    2. Rehabilitation
    3. Home care resources
    4. Patient support groups
    5. Family support groups
    6. Enterostomal therapy
    7. Cost containment
    8. Pre-admission procedures and authorization
    9. Conservation of in-patient resources
    10. Special problems of the elderly
    11. Tumor registry data
  21. Identify available social service and community agency resources to address the issues listed in #20 above.
  22. Describe the anatomy of the breast.
  23. Explain the hormonal regulation of the breast.
  24. Summarize the incidence, epidemiology, and risk factors associated with breast cancer.
  25. Distinguish between these common entities in the differential diagnosis of breast masses:
    1. Fibroadenomas
    2. Cysts
    3. Abscesses
    4. Fibrocystic disease
    5. Fat necrosis
    6. Cancer
  26. Explain the general indications, uses, and limitations of mammography. Define the importance and impact of screening mammography.
  27. Discuss the principles and historic context of the basic options available for the treatment of breast cancer such as:
    1. Radical mastectomy
    2. Modified mastectomy
    3. Lumpectomy and axillary dissection
  28. Outline the genetic and environmental factors associated with carcinoma of the breast.
  29. Describe the following pathological types of breast cancer, including the biology, natural history, and prognosis of each:
    1. Infiltrating ductal carcinoma
    2. Ductal carcinoma in situ (DCIS)
    3. Infiltrating lobular carcinoma
    4. Lobular carcinoma in situ
  30. Describe the presentation, natural history, pathology, and treatment of the following benign breast diseases:
    1. Lactational breast abscess
    2. Chronic recurring subareolar abscess
    3. Intraductal papilloma
    4. Atypical epithelial hyperplasia
    5. Fibroadenoma
  31. Explain the steps in the clinical decision tree that are involved in the work-up of a breast mass.
  32. Discuss the role of mammography, needle aspiration, fine-needle biopsy, open biopsy, and mammographic needle localization and biopsy.
  33. Explain the mechanics and potential value of the stereotactic needle biopsy.
  34. Outline the diagnostic work-up and the differential diagnosis of various forms of nipple discharge.
  35. Explain the use of tumor, nodes, and metastases (TNM) staging in the treatment of breast cancer.
  36. Summarize the rationale for using a team approach to facilitate the complex discussions and explanation of options for the newly diagnosed breast cancer patient prior to definitive treatment (e.g., team of oncologist, surgeon, plastic surgeon, and radiation therapist).
  37. Explain the role of reduction and augmentation mammoplasty.
  38. Discuss several causes of gynecomastia and outline an appropriate work-up.
  39. Describe the normal anatomy, histology, physiology, and pertinent biochemistry of the following organs:
    1. Thyroid gland
    2. Parathyroid gland
    3. Hypothalamus
    4. Pituitary gland
    5. Endocrine pancreas
    6. Adrenal glands
    7. Gastrointestinal tract as an endocrine organ
    8. Gonads as endocrine organs
  40. Discuss fully the secretion and the control thereof of the following:
    1. Thyroxine and thyroid stimulating hormone
    2. Parathyroid hormone
    3. Adrenocorticotropic hormone (ACTH)/cortisol
    4. Insulin/glucagon
    5. Catecholamines (epinephrine, norepinephrine, dopamine)
    6. Gastrin/secretin/cholecystokinin
    7. Serotonin/histamine
    8. Estrogen/progesterone/testosterone (and their releasing factors)
    9. Oxytocin/vasopressin
    10. Growth hormone
    11. Melanocyte stimulating hormone
    12. Prolactin
    13. Motilin/gastric inhibitory peptide/enteroglucagon/vasoactive intestinal peptide
    14. Somatostatin
  41. Summarize the following aspects of endocrine pathology:
    1. The criteria for the diagnosis of malignancy
    2. Chromosomal abnormalities as a screening/diagnostic tool
    3. The unique characteristics about the clinical epidemiology of patients with sporadic versus familial disease
    4. Define and differentiate multiple endocrine neoplasia (MEN) type I, MEN II, and familial non-MEN syndromes
    5. Fine-needle aspiration biopsy
    6. DNA ploidy
  42. Explain the integrated concept of clinical neuroendocrinology, the cells and organs of the amine precursor uptake decarboxylase (APUD) system, and the known clinical endocrine syndromes.
  43. Outline the approach to the surgical management of diseases of the endocrine systems:
    1. Is the treatment of each disease primarily surgical or medical?
    2. Is surgical treatment different for benign versus malignant disease?
    3. Is surgical treatment curative or palliative?
    4. Is surgical treatment directed at the target organ or primary organ?
    5. What role does lesion localization play in endocrine disorders?
  44. Discuss the pathophysiology, clinical presentation, work-up, and treatment of the following diseases:
    1. A solitary thyroid nodule
    2. A multinodular thyroid gland
    3. Thyrotoxicosis
    4. Primary, secondary, and tertiary hyperparathyroidism
    5. Insulinoma/glucagonoma/vipoma
    6. Zollinger-Ellison syndrome
    7. Gastrointestinal carcinoid tumors
    8. Endogenous hypercortisolism (Cushing's syndrome vs. Cushing's disease; secondary to pituitary, adrenal, and ectopic causes)
    9. Pheochromocytoma
    10. Primary hyperaldosteronism
    11. The incidentally discovered adrenal mass
    12. Galactorrhea
    13. Gigantism/dwarfism
  45. Discuss the pre-operative preparation/management of the following:
    1. Hypercalcemic crisis
    2. Thyroid "storm"
    3. Grave's disease/Hashimoto's disease
    4. Pheochromocytoma
    5. Hyperaldosteronism
    6. Endogenous hypercortisolism
    7. Insulinoma/gastrinoma
    8. Carcinoid syndrome
    9. Adrenal insufficiency crisis
  46. Outline the differential diagnosis of:
    1. Hypercalcemia
    2. Hypoglycemia
    3. Hypergastrinemia
    4. Elevated serum thyroxine level
    5. A decreased sensitive thyroid stimulating hormone (TSH) level
    6. Elevated ACTH levels
  47. Discuss corticosteroid administration for elderly patients for diseases more common in that population. Explain the following disease entities as they relate to problems in the elderly patient:
    1. Cushings syndrome
    2. Exogenous hypercortisolism
    3. Chronic alcohol abuse
    4. Chronic intake of self-administered arthritis pills
  48. Discuss the surgical approaches to:
    1. The left adrenal gland
    2. The right adrenal gland
    3. The anterior pituitary gland
    4. The head of the pancreas
    5. The body/tail of the pancreas
    6. The inferior parathyroid glands
    7. The superior parathyroid glands
    8. A retrosternal goiter
  49. Identify and discuss areas of endocrine surgery in which patient management is controversial and areas in which change is taking place, including:
    1. Zollinger-Ellison syndrome
    2. Thyrotoxicosis
    3. Genetic screening for neuroendocrine syndromes
    4. Minimally invasive parathyroidectomy
  50. Summarize key physiologic alterations of the neuroendocrine system that occur with normal aging. Include explanation of these alterations that can occur with advancing age:
    1. Plasma noradrenaline concentrations increase
    2. Steady decrease in aldosterone secretion
    3. Plasma renin activity declines
    4. Plasma cortisol levels significantly increase
  51. Summarize significant issues in the management of anesthesia in endocrine surgery, including:
    1. Airway management during neck surgery
    2. Cardiovascular manipulation during thyroid and pheochromocytoma operations
    3. Special attention to electrolyte management
  52. Critique the role of the following developments in the surgical management of endocrine problems:
    1. Localizing modalities (e.g., metaiodobenzylguanine [MIBG], sestamibi, selective venous sampling, intraoperative tumor localization, rapid parathyroid hormone [PTH] assays)
    2. Diagnostic assays (e.g., sensitive TSH, C-peptide, fine needle aspiration)

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for surgical oncology 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 surgical oncology 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 operative 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 surgical oncology practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding surgical oncology

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-1 on the surgical oncology 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 surgical oncology service as assigned by the Attending
  6. Round on post surgical service patients as instructed.
  7. Attend educational conferences
  8. Complete surgical case logs
  9. Dictate in a timely fashion
  10. Take night 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 surgical oncology 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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