Supervision: PGY-5 → Attending

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
    • Schwartz's Principles of Surgery
    • Cameron’s Current Surgical Therapy
    • SCORE curriculum modules 
  2. Conferences
    • 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. 

Objective: The resident will be able to:

  1. Demonstrate the capability for independent function in all aspects of cancer patient management, including palliative care planning
  2. Prepare and defend the pre-operative assessment plan for the elderly patient in preparation for:
    • Pulmonary resection of all types
    • Esophagectomy and thymus resection
    • Mastectomy
    • Thyroid/parathyroid resection/adrenalectomy, melanoma and other skin cancers
    • Radical mastectomy
    • Modified mastectomy
    • Lumpectomy and axillary dissection
    • Sentinel lymph node biopsy
    • Excision of lactiferous duct fistula
    • Needle-localized breast biopsy
    • Simple mastectomy for gynecomastia
    • Neumonectomy
  3. Stage specific neoplasms clinically and pathologically using the TNM system
  4. Prepare patients medically for cancer surgery, including correction of nutritional and metabolic deficits.
  5. Specify and prepare management plans for nutritional support in the elderly patient. Indicate differences to be expected in requirements compared to patients less than 50 years of age
  6. Assess the need and institute appropriate monitoring both pre- and post-operatively.
  7. Prepare an operative plan for treatment of malignant diseases
  8. Perform colostomies, colostomy closures, and bowel anastomoses of all types/perform tracheostomies, chest tubes and other airway related procedures
  9. Demonstrate proficiency in the use and interpretation of operative and endoscopic ultrasonography.
  10. Perform, with appropriate supervision, major resections in neck, chest, abdomen, breast, and extremity, including complex operative procedures (pneumonectomy, lobectomy, VATS, major neck dissections, esophagectomy, mastectomy with or without sentinel lymph node dissection).
  11. Demonstrate proficiency in endoscopic ultrasonography for placement of esophageal stents
  12. Demonstrate proficiency in gamma probe-directed or dye-directed sentinel lymph node biopsy for breast cancer and melanoma
  13. Assume responsibility for managing the psychosocial aspects of neoplastic diseases
  14. Utilize appropriate social agencies and support groups in cancer patient management.
  15. Assume teaching responsibilities for junior residents as assigned
  16. Use laser therapy, photodynamic therapy, and cryotherapy when indicated, observing proper precautions.
  17. Participate in a multidisciplinary tumor boards
  18. Independently evaluate a new breast, pulmonary and esophagus  patient through history and physical examination, ordering appropriate and cost-effective tests such as mammogram, ultrasound, or fine-needle aspiration (FNA), endoscopy, CT scans, PET scans and PFT’s.
  19. Formulate a diagnostic work-up and treatment plan for most common breast, lung  and esophageal problems, including the common types of breast, lung and esophageal  carcinomas..
  20. Consult and interact with other members of the professional cancer team in explaining options to the newly diagnosed breast, lung and esophageal cancer patient.
  21. Perform, under direct supervision, more advanced procedures on the breast and thorax such as:
    • Lobectomy
    • Wedge resection
    • VATS
    • Esophagectomy
    • Mediastinal procedures
  22. Acquire basic experience with breast reconstruction and cosmetic surgical techniques.
  23. Evaluate the physical status of patients who report for evaluation of augmentation and reduction mammoplasties.
  24. Prescribe various types of adjuvant therapy such as:
    • Chemotherapy
    • Hormonal therapy
    • Radiation therapy
    • Inflammatory carcinoma
    • Paget's Disease
  25. Manage usual and unusual breast and thoracic diseases such as:
    • Lactiferous duct fistula
    • Mondor's Disease
    • Bilateral breast cancer
    • Male breast cancer
    • Cystosarcoma phyllodes
    • Mesothelioma
    • Diffuse pulmonary infiltrates
    • Dyphagia
    • Hemoptysis
    • Non neoplastic lung disease
    • Chest wall abnormalities
    • Congenital abnormalities
    • Tracheal and bronchial abnormalities
    • Diaphragmatic abnormalities
    • Treatment of breast cancer with curative intent
    • Treatment of DCIS
    • Biopsy which revealed fribroadenoma, benign epithelial hyperplasia, or fibrocystic disease with atypia
    • Treatment of lung cancer and other cancers involving the thoracic organs
    • Treatment of esophageal cancer
  26. Describe the evolving role of bone marrow transplantation in the management of selected breast cancer patients.
  27. Outline an appropriate follow-up schedule for patients who have undergone:
  28. Develop a comprehensive plan for the surgical management of endocrine diseases
  29. Perform or assist in the performance of adrenal, pancreas, thyroid, and parathyroid surgery.
  30. Evaluate patients with complex endocrine disease and present a differential diagnosis.
  31. Perform surgery on the adrenals, pancreas, thyroid, and parathyroids.
  32. Independently manage the diagnosis, pre- and post-operative care, and surgery for a variety of endocrine surgery cases.
  33. Understand the indications for minimally invasive parathyroidectomy.
  34. Understand the indications for minimally invasive esophagectomy
  35. Understand the indications for VATS

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 knowledge of the anatomy, physiology, and pathophysiology of the breast, lung, pleura and esophagus,  demonstrate the ability to surgically manage diseases of the breast, lungs, pleura and esophagus  and understand the advancements of minimally invasive/conservative breast surgeries and minimally invasive esophageal and thoracic surgery.

Objectives: The resident will be able to:

  1. Apply clinical screening for common malignancies involving the thoracic cavity, breast and other endocrine organs. 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 breast, lung, pleura and esophagus with regard to survival
  10. Identify margins of resection and how this relates to local recurrence
  11. Describe the indications for and actions of pharmacologic support in the post-operative state
  12. Describe the indications and means for implementing nutritional support in the pre- and post-operative cancer patient.
  13. Explain the fundamental principles of radiation oncology and detail its application as a primary therapy for the treatment of selected benign and malignant lesions.
  14. Summarize the indications and appropriate modalities for adjuvant therapy within the scope of general surgery, including chemotherapy, radiation therapy, immunotherapy, and gene therapy.
  15. Describe radioimmunoguided surgery (RIGS) and its clinical applications.
  16. Explain the rationale and methodology employed in lymphatic mapping and sentinel node biopsies along with the expected level of positive findings.
  17. Understand the surgical options for venous access and oncologic care, and their risks/complications.
  18. Describe the criteria and necessary procedures for intraoperative monitoring of cardiovascular and pulmonary functions of the cancer patient.
  19. Analyze and explain an holistic approach to the treatment of patients with cancer.
  20. Analyze the medical preparation of patients for cancer surgery to include the correction of metabolic and nutritional deficits.
  21. Indicate the potential alterations in pulmonary function in the elderly patient which may affect pre-operative preparation and post-operative management.
  22. Identify the indications of anticipated need in elderly patients for:
    • Post-operative urinary tract decompression
    • Nutritional support
    • Thromboembolism prophylaxis
    • Inflammatory carcinoma
    • Paget's Disease
    • Lactiferous duct fistula
    • Mondor's Disease
    • Cystosarcoma phyllodes
    • Bilateral breast carcinoma
    • Male breast carcinoma
    • Mesothelioma
    • Diffuse pulmonary infiltrates
    • Dyphagia
    • Hemoptysis
    • Non neoplastic lung disease
    • Chest wall abnormalities
    • Congenital abnormalities
    • Tracheal and bronchial abnormalities
    • Diaphragmatic abnormalities
    • Chemotherapy
    • Radiation therapy
    • Hormonal therapy
  23. Define and apply the criteria for palliative versus curative treatment plans.
  24. Analyze and explain the rationale for combined adjuvant modalities in the prevention and treatment of cancer recurrence
  25. Apply proper clinical and demographic data to the tumor registry.
  26. Outline the indications for and initiate requests for appropriate consultation.
  27. Demonstrate a working knowledge of prior research milestones, current research efforts, and cancer research methodology.
  28. Describe the characteristics, diagnosis, and therapy of less common  lesions of the breast and thoracic lesions such as:
  29. Understand the methodologies and results of landmark breast cancer trials: B-04, B-06, B-17, B-24 (NSABP)
  30. Define appropriate breast conservation therapies, their benefits, and comparative outcomes, and compare them with modified radical mastectomy.
  31. Summarize the role of adjuvant chemotherapy and radiation therapy for the treatment of primary breast carcinoma
  32. Outline the importance of estrogen and progesterone receptors in the prognosis and treatment of breast cancer.
  33. Describe the basic issues in the staging and treatment of metastatic breast cancer, including the role of:
  34. Summarize the physiologic changes associated with pregnancy, including breast problems peculiar to pregnancy. Theorize appropriate management of breast cancer diagnosed during pregnancy.
  35. Formulate plans for basic patient care, including pre-, intra-, and post-operative car
  36. Summarize the major considerations for post-mastectomy breast reconstruction.
  37. Identify and analyze the data addressing controversial areas of breast disease, such as:
    • Current concepts in the management of cancer
    • Cancer prevention techniques, such as tamoxifen and raloxifene
    • Role of various adjuvant therapy programs.
    • Biological behavior of lesions such as lobular carcinoma in situ
    • Benefit and frequency of screening mammograms
    • Relationship of mammographic parenchymal patterns to the risk of subsequent malignancy
    • Role of breast cancer susceptibility genes
    • Monoclonal antibodies
    • Other breast markers, including Her-2/neu, cathepsin D, and flow cytometry with chromosomal analysis
  38. Review and evaluate the following areas of research in breast disease: 
  39. Explain the role of sentinel lymph node biopsy for breast cancer
    • Sensitivity and specificity
    • Indication and contraindications
    • Technique
    • Treatment plan based on findings
    • Thyroid gland
    • Parathyroid gland
    • Hypothalamus
    • Pituitary gland
    • Endocrine pancreas
    • Adrenal glands
    • Gastrointestinal tract as an endocrine organ
    • Gonads as endocrine organs
    • Thyroxine and thyroid stimulating hormone
    • Parathyroid hormone
    • Adrenocorticotropic hormone (ACTH)/cortisol
    • Insulin/glucagon
    • Catecholamines (epinephrine, norepinephrine, dopamine)
    • Gastrin/secretin/cholecystokinin
    • Serotonin/histamine
    • Estrogen/progesterone/testosterone (and their releasing factors)
    • Oxytocin/vasopressin
    • Growth hormone
    • Melanocyte stimulating hormone
    • Prolactin
    • Motilin/gastric inhibitory peptide/enteroglucagon/vasoactive intestinal peptide
    • Somatostatin
    • The criteria for the diagnosis of malignancy
    • Chromosomal abnormalities as a screening/diagnostic tool
    • The unique characteristics about the clinical epidemiology of patients with sporadic versus familial disease
    • Define and differentiate multiple endocrine neoplasia (MEN) type I, MEN II, and familial non-MEN syndromes
  40. Describe the normal anatomy, histology, physiology, and pertinent biochemistry of the following organs:
  41. Discuss fully the secretion and the control thereof of the following:
  42. Summarize the following aspects of endocrine pathology:
    • Fine-needle aspiration biopsy
    • DNA ploidy
    • Is the treatment of each disease primarily surgical or medical?
    • Is surgical treatment different for benign versus malignant disease?
    • Is surgical treatment curative or palliative?
    • Is surgical treatment directed at the target organ or primary organ?
    • What role does lesion localization play in endocrine disorders?
  43. 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.
  44. Outline the approach to the surgical management of diseases of the endocrine systems: 
  45. Discuss the pathophysiology, clinical presentation, work-up, and treatment of the following diseases:
    • A solitary thyroid nodule
    • A multinodular thyroid gland
    • Thyrotoxicosis
    • Primary, secondary, and tertiary hyperparathyroidism
    • Insulinoma/glucagonoma/vipoma
    • Zollinger-Ellison syndrome
    • Gastrointestinal carcinoid tumors
    • Endogenous hypercortisolism (Cushing's syndrome vs. Cushing's disease; secondary to pituitary, adrenal, and ectopic causes)
    • Pheochromocytoma
    • Primary hyperaldosteronism
    • The incidentally discovered adrenal mass
    • Galactorrhea
    • Gigantism/dwarfism
    • Hypercalcemic crisis
    • Thyroid "storm"
    • Grave's disease/Hashimoto's disease
    • Pheochromocytoma
    • Hyperaldosteronism
    • Endogenous hypercortisolism
    • Insulinoma/gastrinoma
  46. Discuss the pre-operative preparation/management of the following:
    • Carcinoid syndrome
    • Adrenal insufficiency crisis
    • Hypercalcemia
    • Hypoglycemia
    • Hypergastrinemia
    • Elevated serum thyroxine level
    • A decreased sensitive thyroid stimulating hormone (TSH) level
    • Elevated ACTH levels
    • Cushing's syndrome
    • Exogenous hypercortisolism
    • Chronic alcohol abuse
    • Chronic intake of self-administered arthritis pills
    • The left adrenal gland
    • The right adrenal gland
    • The anterior pituitary gland
    • The head of the pancreas
    • The body/tail of the pancreas
    • The inferior parathyroid glands
    • The superior parathyroid glands
    • A retrosternal goiter
    • Zollinger-Ellison syndrome
    • Thyrotoxicosis
    • Genetic screening for neuroendocrine syndromes
    • Minimally invasive parathyroidectomy
    • Plasma noradrenaline concentrations increase
    • Steady decrease in aldosterone secretion
    • Plasma renin activity declines
    • Plasma cortisol levels significantly increase
    • Airway management during neck surgery
    • Cardiovascular manipulation during thyroid and pheochromocytoma operations
    • Special attention to electrolyte management
    • Localizing modalities (, metaiodobenzylguanine [MIBG], sestamibi, selective venous sampling, intraoperative tumor localization, rapid parathyroid hormone [PTH] assays)
    • Diagnostic assays (, sensitive TSH, C-peptide, fine needle aspiration)
  47. Outline the differential diagnosis of:
  48. 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:
  49. Discuss the surgical approaches to:
  50. Identify and discuss areas of endocrine surgery in which patient management is controversial and areas in which change is taking place, including:
  51. Summarize key physiologic alterations of the neuroendocrine system that occur with normal aging.  Include explanation of these alterations that can occur with advancing age:
  52. Summarize significant issues in the management of anesthesia in endocrine surgery, including:
  53. Critique the role of the following developments in the surgical management of endocrine problems:
  54. Discuss the diagnosis, evaluation, and definitive treatment of patients with common thoracic surgery problems including:
    • Solitary pulmonary nodule b.          
    • Lung cancer
    • Esophageal motility disorders d.         
    • Mediastinal adenopathy
    • Pleural effusion
    • Diffuse pulmonary infiltrates.          
    • GERD
    • Pneumothorax            
    • Mesothelioma
    • Dyspnea
    • Hemoptysis          
    • Dysphagia
    • Lobar and segmental anatomy of the lungs
    • Lobar and segmental anatomy of the bronchovascular tree
    • Esophagus, its anatomic relationships, and surgical access
    • Nerves: vagus, phrenic, sympathetic
    • Great vessels and their surgical access
    • Diaphragm and its surgical access
    • Esophagogastric motility
    • Respiratory gas exchange
    • Ventilatory gas exchange
    • Fluids and electrolytes
    • Immune system function
    • Immunosuppression
    • Coagulation system and its disturbances
    • Intra-/postoperative fluid status
    • Chest tube management
    • Pain control
    • Enteral nutrition
    • Coagulation abnormalities
    • Glucose and electrolyte abnormalities
    • Chest pain
    • Sinus tachycardia
    • Atrial fibrillation
    • Low urine output
    • Transfusion reaction
    • Pulmonary embolism
    • Alcohol withdrawal
    • Pneumothorax
    • Wound infection
  55. Know the relevant anatomy of the thorax.
  56. Learn relevant detailed physiology.
  57. Management of the postoperative patient.
  58. Learn to recognize and treat common post-operative complications: 
  59. Learn details of ventilatory management
    • Modes of ventilation
    • Oxygenation techniques
    • Ventilation techniques
    • Weaning strategies

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-5 on the Surgical Oncology (Breast and Thoracic)  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 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 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.

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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