Specific Educational Goals and Education

Level: PGY-3

Service: UH1

Supervision: PGY-3 → Chief Resident → Attending

All management decisions will be discussed with the senior resident and 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 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. Schwartz's Principles of Surgery
    2. SCORE curriculum modules
  2. Conferences
    1. Wednesday Resident Educational Curriculum

Competency Based Performance Objectives:

Patient Care:

Goal: Through the acquired skills and knowledge of general surgery principles the resident can demonstrate the ability to manage disease and injury of the general surgery patient amenable to surgical intervention.

Objective: The resident will be able to:

  1. Perform, record, and report complete patient evaluation and assessment.
  2. Evaluate emergency department or clinic patients who present with problems referable to the GI tract.
  3. Evaluate and diagnose the acute abdomen.
  4. Evaluate and manage nutritional needs (enteral and parenteral) of surgical patients until normal GI function returns.
  5. Serve as assistant to the primary surgeon during operations of the esophagus, stomach, small intestine, colon, and anorectal.
  6. Perform less complicated surgical procedures such as:
    1. Gastrostomy
    2. Meckel's diverticulectomy
    3. Appendectomy
    4. Hemorrhoidectomy
    5. Anal fissurectomy and fistulectomy
    6. Incision and drainage of perirectal abscesses
  7. Accept responsibility for the post-operative management of:
    1. Nasogastric tubes
    2. Intestinal tubes
    3. Intra-abdominal drains
    4. Intestinal fistulas
    5. Abdominal incisions (simple and complicated)
  8. Provide follow-up care to the surgical patient in the outpatient clinic or surgical office.
  9. Assist with hernia repairs in the groin or umbilicus, demonstrating a basic understanding of the anatomy and surgical repair.
  10. Interpret the following in coordination with attending radiologists and staff; upper GI series, barium enema, and abdominal ultrasound and CT scans.
  11. Evaluate and institute management of abdominal wound problems, including; infection, evisceration, fasciitis, and dehiscence.
  12. Coordinate pre- and post-operative care for the patient with the acute abdomen.
  13. Institute drainage for abdominal wall fistula and protection of surrounding structures, especially skin.
  14. Assist in closure of abdominal incisions; exhibit competency in suture techniques.
  15. Perform history and physical examination specifically focused on liver and biliary system.
  16. Select and interpret appropriate laboratory and radiologic evaluations in the work-up of the jaundiced
  17. Perform uncomplicated hepatobiliary surgery under supervision, such as cholecystectomy, both laparoscopic and open, with operative cholangiography.
  18. Assist in more advanced hepatobiliary operations.
  19. Perform history and physical examination focused on the pancreas.
  20. Select and interpret appropriate laboratory and radiologic examinations in evaluation of pancreatic disease
  21. Assist in management of patient with acute pancreatitis.
  22. Assist in perioperative management of patients undergoing pancreatic surgery.
  23. Perform minor pancreatic procedures under supervision such as external drainage of pseudocyst or internal drainage via cystgastrostomy.

Competency Based Knowledge Objectives:

Medical Knowledge:

Goal: Demonstrate an understanding of the anatomy, physiology, and pathophysiology of the alimentary tract and digestive system and be able to demonstrate the ability to manage those problems that are amenable to surgical intervention.

Objectives: The resident will be able to:

  1. Define the basic scientific principles of the alimentary tract and digestive system diseases to include:
    1. Anatomy, embryology, and biochemistry of the gastrointestinal (GI) tract
      1. Embryologic development of primitive foregut and hindgut and its appendages, including normal rotation and fixation
      2. Histology of alimentary tract, including differentiation of cell types
      3. Anatomy of alimentary tract from esophagus to anus with emphasis on systemic blood supply, portal venous drainage, neural-endocrine axis, and lymphatic drainage
      4. Abdominal anatomy, explaining its relationship to lower thorax, retroperitoneum, and pelvic floor
      5. Mucosal transport, including mechanism of absorption of nutrients and water
      6. Sites of electrolyte and acid-base regulation
    2. GI physiology
      1. Physiology of deglutition and phases of digestion
      2. Neuroendocrine control of GI secretion and motility
      3. Regional controls of mucosal secretion and absorption (neural and hormonal)
      4. Enterohepatic circulation
      5. Neuromuscular control of defecation
      6. Digestion of sugars, fats, proteins, vitamins, and cofactors
      7. Rates of mucosal turnover
      8. Nutritional needs of surgical patients
      9. Normal secretory rates for the stomach, small bowel, biliary tree, and pancreas
    3. Normal bacterial flora and their concentrations in the upper and lower GI tract
    4. Immunologic properties of the GI tract and how this barrier is affected by: trauma, sepsis, burns, malnutrition, and chronic disease
    5. Principles of intestinal healing
      1. Normal GI tissue integrity and strength and how this relates to healing of anastomoses
      2. Effects of suturing and stapling techniques of the gut
  2. Explain and give examples for the following aspects of gastrointestinal diseases:
    1. Infections inside and outside the GI tract from esophagus to anus, including the peritoneum
    2. Embryologic abnormalities of the GI tract, including:
      1. Strictures
      2. Stenoses
      3. Webs
      4. Atresias
      5. Duplications
      6. Malrotations
    3. Congenital and acquired abnormalities of gut motility
    4. Neoplasia of the GI tract
    5. Ulceration of the proximal and distal GI tract
    6. Causes of GI obstruction
    7. Causes of paralytic ileus
    8. Causes of GI hemorrhage
    9. Causes of GI perforation
    10. Causes of abdominal abscess formation or secondary peritonitis
    11. Short gut and malabsorptive conditions
    12. Acute and chronic mesenteric ischemia
    13. Portal hypertension and venous thrombosis
    14. Inflammatory bowel diseases
    15. Causes of an acute abdomen
    16. Management of intestinal ostomies
    17. Traumatic injury to abdominal viscera
    18. Ischemic bowel
  3. Discuss some of the more common diseases of the esophagus in elderly patients, to include:
    1. Motility disorder
    2. Esophageal injuries
    3. Diverticular disease
    4. Inflammatory disease
    5. Gastroesophageal reflux
    6. Tumors (benign and malignant)
  4. Outline the essential characteristics of routine and highly specialized diagnostic evaluation of the alimentary tract, including:
    1. History
      1. Pain
      2. Nausea/emesis
      3. Bowel function
      4. Prior episodes
      5. Past surgical history
    2. Physical examination:
      1. Inspection
      2. Auscultation
      3. Percussion
      4. Palpation
    3. Radiologic examinations, including:
      1. Barium swallow
      2. Upper GI Series with small bowel follow-through
      3. Enteroclysis
      4. Ultrasound
      5. Transesophageal echo
      6. Computerized Tomography
      7. Magnetic Resonance Imaging
      8. Barium enema
      9. Angiograms
      10. Nuclear scans for bleeding or to evaluate for Meckel's diverticulum
    4. Fiberoptic endoscopy
    5. Rigid anoscopy and sigmoidoscopy
    6. Tests of GI function including:
      1. Manometry
      2. pH measurement
      3. Gastric analysis (basal and stimulated)
      4. Radioisotope clearance studies
        1. Technetium 99m
        2. Technetium HIDA (hepatic 2,6-dimethyliminodiacetic acid) dynamic biliary imaging
      5. Gastric emptying studies
      6. Transit times
      7. Hormonal determinations
      8. Absorption
  5. Summarize current medical management and its potential limitations; explain the role of surgical intervention when management fails in the following:
    1. Peptic ulcer disease
    2. Esophageal varices
    3. Upper and lower GI bleeding
    4. Gastroparesis
    5. Inflammatory bowel disease
    6. Diverticulitis
  6. Describe the embryological development of the peritoneal cavity and the positioning of the abdominal viscer
  7. Diagram the anatomy of the abdomen including its viscera and anatomic spaces:
    1. Musculoskeletal envelope
    2. Lesser sac
    3. Subphrenic spaces
    4. Morrison's pouch
    5. Foramen of Winslow
    6. Pouch of Douglas
    7. True pelvis
    8. Lateral gutters
    9. Contents of the retroperitoneum
    10. Major lymph node groups and their contents
  8. Surgical outcome is dependent on coexistent disease.  Describe changes in the following organ systems that result from the aging process:
    1. Heart
    2. Lung
    3. Kidney
    4. Brain
    5. Hematopoietic system
    6. Gastrointestinal tract
  9. Explain absorption and secretory functions of the peritoneal surfaces and the diaphragm.
  10. Describe the anatomy of the omentum and its role in responding to inflammatory processes.
  11. Assess the following signs associated with the acute abdomen and describe their pathophysiology:
    1. Referred pain
    2. Rebound tenderness
    3. Guarding
    4. Rigidity
  12. Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for the following processes:
    1. Acute appendicitis
    2. Bowel obstruction
    3. Perforated ulcer
    4. Ureteral colic
    5. Diffuse peritonitis
    6. Biliary colic
  13. List possible distinctions in the presentation and examination of the elderly patient with the following causes of acute abdomen:
    1. Perforated viscus
    2. Cholecystitis
  14. Discuss the differences in the physiologic response to stress in the geriatric patient.
  15. Explain the mechanism of referred pain in:
    1. Ruptured spleen
    2. Biliary colic
    3. Basilar pneumonia
    4. Renal colic
    5. Pancreatitis
    6. Inguinal hernia
  16. Discuss the following causes of paralytic ileus:
    1. Post-operative electrolyte imbalance
    2. Retroperitoneal pathology
    3. Trauma
    4. Extraperitoneal disease (central nervous system, lung)
  17. Illustrate use of the following diagnostic studies in the work-up of each process in #12 and #15 above:
    1. Laboratory evaluation
    2. Urinalysis
    3. Plain x-rays
    4. Contrast gastrointestinal (GI) studies
    5. Ultrasound
    6. Computed axial tomography (CAT)
    7. Biliary studies
    8. Renal studies
  18. When considering the possibility of wound complications:
    1. What are the risk factors for abdominal wound infection?
    2. What are the contributing factors for abdominal wound dehiscence and evisceration?
    3. What are the usual clinical presentations and timing?
    4. What is the incidence of wound infection in surgeries involving the biliary tree, upper GI tract, and colon?
    5. List wound complications that are more problematic in the elderly patient.
  19. Identify the anatomic locations for the following intra-abdominal abscesses; name disease process(es) associated with each:
    1. Left subphrenic space
    2. Right subphrenic space
    3. Subhepatic space
    4. Lesser sac
    5. Interloop
    6. Pelvis
    7. Left paracolic gutter
    8. Right paracolic gutter
    9. Psoas muscle
  20. Differentiate between the conditions favoring percutaneous drainage versus operative drainage for each of the abscesses in #1Describe the safest and most effective approach using each technique.
  21. Differentiate between the following intestinal fistulas and the organs to which they most often communicate:
    1. Esophageal
    2. Gastric
    3. Enteric (including duodenal)
    4. Colonic
  22. Explain the formation of fistulas in each of the following disease processes or factors:
    1. Operative complications (bowel injury with abscess formation)
    2. Inflammatory bowel disease
    3. Acute pancreatitis
    4. Foreign body or prosthetic material
    5. Malignancy
  23. Explain the role of a fistulogram in the diagnosis of intra-abdominal fistulas and abscesses.
  24. List the factors that prevent healing of a fistula.
  25. Summarize the conditions favoring operative versus non-operative treatment for fistulas listed in #1
  26. Describe the anatomy, clinical presentation, and complications of non-operative management for these hernias:
    1. Direct and indirect inguinal, femoral, and obturator
    2. Sliding hiatal
    3. Paraesophageal
    4. Ventral
    5. Umbilical
    6. Spigelian
    7. Paraduodenal
    8. Richter's
    9. Lumbar and Petit
    10. Parastomal
    11. Diaphragmatic
      1. Posterolateral (Bochdalek)
      2. Anterior (Morgagni)
      3. Traumatic
    12. Internal
  27. Name the hernia types that are most common in elderly patients, and explain how they may become problematic.
  28. Define a Richter's hernia and describe its clinical presentation.
  29. Define a sliding hernia and describe its repair.
  30. Differentiate between incarceration and strangulation.
  31. Differentiate between conventional open and scope-assisted surgery, including:
    1. Anesthetic considerations
    2. Effects of pneumoperitoneum
    3. Cardiovascular stability
    4. Need for team participation
    5. Differences in patient outcome
  32. Discuss the physical limitations imposed on the user participating in minimally invasive surgery, including:
    1. Surgeon fatigue and diminished proficiency over time
    2. Two-dimensional perspective
    3. Visual limitations of scope and monitoring equipment
    4. Crucial importance of patient position and cannula position for optimum exposure
  33. Understand strategies to offset the difficulties suggested in #32 above, including:
    1. Proper alignment of eye-camera-instrument axes
    2. Efficient biomechanics
    3. Effective use of assistants
    4. Appropriate use of other advanced technologies such as endoscopic ultrasound
  34. Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem.
  35. Explain the concept of the learning curve, and discuss the need for quality control in the education and evaluation of surgical housestaff in developing proficiency in minimally invasive surgery.
  36. Explain the mechanics and principles for safe and effective use of the following equipment/procedures
    1. Cautery (monopolar and bipolar)
    2. Ultrasonic shears
    3. Laser
    4. Telescopic direction (straight and angled laparoscope)
    5. Insulation technique and hazards
    6. Maintaining visualization of operative field
    7. Dissecting and knot tying
  37. Discuss appropriate anesthetic management for minimally invasive techniques for surgery involving the abdomen, thorax, and joints and soft tissue spaces.
  38. Summarize areas of current investigation in minimally invasive surgery, including:
    1. Virtual reality
    2. Use of robots/robotics
    3. Three-dimensional imaging systems
    4. Dissection techniques for soft tissues
  39. Discuss the potential economic impact of increased utilization of operating room time, advanced equipment, and disposable instruments on health care costs.
  40. Summarize protocols for appropriate cleaning, sterilization, maintenance, and handling of minimally invasive equipment.
  41. Basic Laparoscopic Skills
    1. Discuss techniques for gaining access to the abdomen, including:
      1. Veress needle
      2. Open (Hassan cannula)
      3. Direct visualization trocars
    2. Discuss indications for and limitations of diagnostic laparoscopy, as well as pros and cons of this diagnostic technique compared with other diagnostic modalities such as CT scan or ultrasound.
    3. Discuss recognition and management of complications, including major vascular injury, massive Carbon dioxide embolus, or visceral injury.
    4. List contraindications for laparoscopic surgery, and be able to explain why these conditions are considered relative or absolute contraindications.
  42. Laparoscopic Cholecystectomy (LC)
    1. Discuss the indications and contraindications for laparoscopic cholecystectomy.
    2. Describe the technical aspects of preparing for and operating on a patient undergoing L
    3. Identify major considerations for the decisions involved in converting from laparoscopic to open cholecystectomy, including:
      1. Difficulty identifying anatomy (, common duct)
      2. Poor visibility
      3. Hemorrhage control
    4. Select management options for handling bile duct injuries, including immediate and delayed diagnosis and treatment.
    5. Specify the indications and technique for percutaneous cholangiography, endoscopic ultrasound, and common bile duct exploration (CBDE), including use of choledochoscopy.
    6. Discuss management of the patient with common duct stones, including:
      1. Choice of approach (open common duct exploration, versus laparoscopic CBDE, versus LC followed by/preceded by endoscopic stone extraction)
      2. Timing of surgery
      3. Safety and cost-effectiveness of each approach
  43. Additional Laparoscopic Procedures
    1. Describe current theories, including advantages and disadvantages, regarding the use of laparoscopic anti-reflux procedures and myotomies.
    2. Discuss advantages and limitations of thoracoscopic versus laparoscopic approach for esophagomyotomy.
    3. Discuss indications and contraindications for addition of partial fundoplication to esophagomyotomy.
    4. Describe management of paraesophageal hernia.
    5. Outline the potential benefits and limitations to:
      1. Laparoscopy-assisted colectomy
      2. Pre- and trans- peritoneal groin hernia repairs
      3. Laparoscopic ventral hernia repair
      4. Appendectomy
    6. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
      1. Adrenalectomy
      2. Gastrectomy
      3. Splenectomy
      4. Donor nephrectomy
  44. Describe the anatomy of the liver and biliary system, including commonly found variations.
  45. Describe the physiology and function of liver and biliary system to include:
    1. Glucose metabolism
    2. Protein synthesis
    3. Coagulation
    4. Drug metabolism
    5. Reticuloendothelial system
    6. Function of bile in fat metabolism
  46. Explain the formation of bile, its composition, and its function in digestion.  Describe the pathophysiology of gallstone formation.
  47. Correlate bile formation and composition with disease states affecting the biliary system such as gallstone formation and biliary obstruction.
  48. Discuss the enterohepatic circulation of bile.
  49. Outline the work-up and differential diagnosis of the jaundiced patient.
  50. Identify the most significant determinants of mortality in elderly patients following cholecystectomy.
  51. Discuss various types of liver cysts (echinococcal or hydatid, nonparasitic) and the appropriate management of each.
  52. Discuss the principal characteristics of and the treatment for the following:
    1. Metastatic lesions to the liver
    2. Primary malignancies of liver and biliary tree
    3. Benign tumors of the liver
  53. Summarize the etiologies and management of pyogenic and amebic hepatic abscesses.
  54. Explain types of infectious hepatitis (A, B, C) with:
    1. Modes of transmission
    2. Diagnosis
    3. Time course for serologic conversion
    4. Natural course
  55. Outline the pathophysiology, evaluation, and management of the following:
    1. Choledochal cysts
    2. Caroli's disease
    3. Sclerosing cholangitis
    4. Primary biliary cirrhosis
    5. Secondary biliary cirrhosis
    6. Cholangitis
    7. Gallstone ileus
    8. Gallstone pancreatitis
    9. Benign biliary stricture
    10. Acute cholecystitis
    11. Symptomatic gallstone
    12. Acalculous cholecystitis
    13. Biliary dyskinesia
    14. Congenital biliary atresia
  56. Describe the anatomy of the pancreas, including regional vascular anatomy.
  57. Summarize changes that occur in the anatomy of the pancreas with aging by considering:
    1. Duodenal C loop
    2. Head of the pancreas
    3. Atrophy of pancreas
    4. Pancreatic ductal anatomy
  58. Discuss the physiology of the pancreas, including endocrine and exocrine function and hormonal regulation.
    1. Endocrine--islet cells
      1. Alpha (Glucagon)
      2. Beta (Insulin)
      3. Delta (Somatostatin)
      4. Non-Beta (pancreatic polypeptide)
    2. Exocrine--acinar cells
      1. Lipase
      2. Amylase
    3. Hormonal regulation
      1. Secretin--bicarbonate secretion
      2. Cholecystokinin--enzyme secretion
  59. Explain the pathophysiology of pancreatitis to include:
    1. Common etiologies such as:
      1. Gallstones
      2. Alcohol related
      3. Trauma
      4. Medications
      5. Post-operative
      6. Post endoscopic retrograde cholangiopancreatography (ERCP)
      7. Idiopathic
    2. Diagnosis, evaluation, and medical management
    3. Role of peritoneal lavage
    4. Complications of pancreatitis, such as:
      1. Adult respiratory distress syndrome (ARDS; Acute lung injury-ALI also used)
      2. Hypovolemia
      3. Pseudocyst
      4. Abscess
      5. Sterile pancreatic necrosis
      6. Infected pancreatic necrosis
    5. Indications for operative management of pancreatitis
    6. Management of gallstone pancreatitis with timing of surgery
    7. Methods of prognostic assessment
  60. Describe the incidence of these diseases in the elderly patient:
    1. Cholelithiasis
    2. Acute gallstone pancreatitis
    3. Pancreatic carcinoma
  61. Explain the pathophysiology of carcinoma of the pancreas to include:
    1. Typical history and presentation
    2. Diagnostic evaluation using:
      1. Computed axial tomography
      2. Ultrasound
      3. ERCP
      4. Percutaneous transhepatic cholangiography (PTC)
      5. Arteriography
      6. Laparoscopy/laparotomy
    3. Indications for:
      1. Operative versus nonoperative biliary drainage
      2. Percutaneous versus endoscopic stenting
      3. Resection
      4. Concomitant gastrojejunostomy with operative biliary bypass
  62. Discuss presentation, evaluation, and management of pancreatic pseudocysts with attention to:
    1. Complications of pseudocysts (hemorrhage, infection, rupture)
    2. Timing of drainage
    3. Percutaneous versus surgical drainage
    4. Indications for external versus internal drainage
    5. Choice of internal drainage procedure
  63. Explain the diagnosis and management of pancreatic ascites.

Interpersonal and Communication Skills:

Goal: Counsel patients and obtain informed consent for general surgery 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 general surgery 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 general surgery practices

Objective: The resident will demonstrate the ability to:

  1. Discuss studies regarding the general surgery procedures

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-3 on the general surgery service
  2. Appropriate, professional supervision of student teaching in light of educational goals
  3. Attend general surgery clinic as assigned
  4. Manage OR patients with supervision
  5. Assist with consultations to the general surgical service as assigned by the Chief Resident
  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 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 general 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.

;