Specific Educational Goals and Education
Level: PGY - 2/3
Service: Endocrine/Breast
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:
- Recommended Reading
- Schwartz's Principles of Surgery
- SCORE curriculum modules
- Conferences
- 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.
Endocrine Surgery Rotation Objectives:
These objectives outline the knowledge and skills that should be taught, learned, and demonstrated by the completion of general surgery residency. Although the field
of endocrine surgery encompasses many uncommon diseases and syndromes, the curriculum is based on common endocrine diseases where the practicing general surgeon is often involved in the care. Other, uncommon syndromes outlined are appropriate for review because of their underlying pathophysiology and presence on standardized examinations. A resident successfully demonstrating all of these objectives will have the appropriate background to perform common endocrine
surgical procedures commensurate with his/her skill and expertise.
Thyroid Disease:
Knowledge objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Outline algorithms for the evaluation and treatment of:
- Well-differentiated thyroid cancer
- Medullary thyroid cancer
- Thyroid lymphoma
- Anaplastic thyroid cancer
- Describe risk factors for well-differentiated thyroid cancer, medullary thyroid cancer, and anaplastic thyroid cancer.
- Outline algorithms for the evaluation and treatment of hyperthyroidism due to Graves’ disease, toxic nodule, medications, and pregnancy.
- Describe the clinical presentation of thyroid storm and outline the treatment of thyroid storm.
- Outline an algorithm for the evaluation and management of nontoxic multinodular goiter, including substernal goiter with and without airway involvement.
- Outline the pathophysiology of:
- Multinodular goiter
- Grave’s disease
- Thyroid cancer
- Describe operative approaches to thyroid pathology
- Outline the staging and prognosis in thyroid cancer
- Recognition and treatment of common postoperative complications
- Hematoma
- Hypocalcemia
- Thyroid storm
- Voice changes
Skill objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Demonstrate normal anatomy in the operating room
- Palpate and describe a thyroid nodule
- Perform a fine needle aspiration biopsy of a palpable thyroid nodule
- Perform the initial steps in thyroid surgery, including
- Patient positioning and marking
- Skin incision and raising subplatysmal flaps
- Opening strap muscles
- Close strap muscles, platysma, and skin
Parathyroid disease:
Knowledge objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Demonstrate in the operating room typical locations for ectopic parathyroid glands.
- Be familiar with current AAES and Endocrine Society guidelines for surgical treatment of asymptomatic patients.
- Discuss the initial evaluation of patients with asymptomatic hyperparathyroidism being considered for observation. This should include an outline of the appropriate follow up of these patients including diagnostic evaluation, frequency of testing, and anticipated outcomes.
- Describe which patients are appropriate candidates for nonoperative management of hyperparathyroidism.
- Outline indications for and interpretation of results of bone density testing.
- Outline outpatient follow up after parathyroidectomy.
- Outline an algorithm for the preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism. Discuss the rationale and accuracy of the various localizing strategies and tests.
- Outline an algorithm for intraoperative confirmation of successful parathyroidectomy during full neck exploration and minimally invasive parathyroidectomy.
- Describe differences between a bilateral 4-gland exploration, a unilateral exploration and a focused exploration
- Outline the prevention, recognition, and management of hungry bone syndrome after parathyroidectomy.
- Outline a diagnostic and treatment pathway for patients with non-MEN familial hyperparathyroidism
- Describe the technique of cryopreservation and its role in the treatment of patients with multigland disease or during reoperative parathyroid surgery
- Outline the interpretation of intraoperative PTH monitoring results and their correlation with postoperative eucalcemia
Skill objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Demonstrate normal parathyroid anatomy in the operating room at the time of parathyroidectomy or thyroidectomy.
- Interpret a sestamibi scan.
- Perform the following steps of parathyroidectomy (Be able to describe difference in performing a full neck exploration, minimally invasive approach, unilateral or focused)
- Patient positioning and marking
- Skin incision and raising subplatysmal flaps
- Opening strap muscles
- Close strap muscles, platysma, and skin
Adrenal disease:
Knowledge objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Outline the diagnostic pathway of ACTH dependent vs. ACTH independent Cushing’s syndrome, including the role of the low and high dose dexamethasone suppression test. Understand normal ranges and those expected for suppression of cortisol and be familiar with the utility and role of salivary, venous and urinary cortisol assessments.
- Describe the localization studies available for adrenal tumors, including CT scanning, MIBG, PET scanning with FDG or DOTATATE, and MRI.
- Distinguish bilateral hyperplasia vs. unilateral disease in Cushing’s syndrome and primary hyperaldosteronism.
- Describe the diagnostic algorithm for primary hyperaldosteronism.
- Describe the treatment and outcome for primary hyperaldosteronism in patients treated with adenoma vs. bilateral adrenal hyperplasia.
- Outline the diagnostic evaluation and treatment of adrenocortical carcinoma.
- Outline the diagnostic pathway for pheochromocytoma and review of the treatment modalities and recommendations.
- Describe the evaluation and treatment of an adrenal incidentaloma.
- Explain the etiology, diagnosis, and treatment of adrenal cystic disease.
- Explain the role of fine needle aspiration biopsy in the evaluation of adrenal tumors.
- Describe operative approaches for adrenal surgery, including the laparoscopic trans- and extraperitoneal approaches and anterior, lateral and posterior open approaches.
- Understand functioning imaging modalities for pheochromocytoma and adrenal hyperplasia (i.e., MIBG, DOTATATE or NP 59 scanning)
- Understand technique involved with adrenal vein sampling; role of ACTH stimulation and cortisol assessment to document accuracy of catheter location.
- Understand algorithm and dosing of preoperative preparation/blockade for pheochromocytoma
- Be familiar with medications that can alter interpretation of catecholamines (i.e. antidepressants, Tylenol, etc)
Skill objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Identify adrenal anatomy, blood supply, and surrounding structures at the time of adrenalectomy or other operation.
- Demonstrate operative exposure (open, laparoscopic, or retroperitoneoscopic) of either adrenal gland.
Gastrointestinal neuroendocrine tumors:
GINETs are rare entities. Therefore, the focus of this section is on gastrointestinal hormone pathophysiology and recognition of syndromes associated with tumors producing these hormones. Because of the rarity of these tumors and syndromes, only knowledge objectives are incorporated in this section of the curriculum.
Knowledge objectives
By the completion of the third year, the general surgery resident should be able to:
- Describe the site of synthesis, mechanism of action, and normal physiologic effects of the following gastrointestinal hormones
- Gastrin
- Insulin
- Glucagon
- Vasoactive Intestinal Peptide
- Somatostatin
- Describe the different cell types of the endocrine pancreas, their synthetic products, stimuli and inhibitors to these products, and distribution in the pancreas.
- Describe the symptoms and syndromes associated with the hypersecretion of the following gastrointestinal hormones:
- Gastrin
- Insulin
- Glucagon
- Vasoactive Intestinal Peptide
- Somatostatin
- Describe the typical presentation of carcinoid tumors.
- Describe the sites of occurrence of carcinoid tumors including their frequency and propensity for developing carcinoid syndrome.
- Describe the pathophysiology of carcinoid syndrome.
Breast Surgery Rotation Objectives:
These objectives outline the knowledge and skills that should be taught, learned, and demonstrated by the completion of general surgery residency. Benign and malignant breast disease is a common presentation to the practicing general surgeon and high yield in the examination setting. Management of the high risk breast patient is an important and examinable skill. A resident successfully demonstrating all of these objectives will have the appropriate background to perform common breast surgical procedures commensurate with his/her skill and expertise.
Breast Disease:
Knowledge objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Develop a diagnostic and therapeutic plan, including appropriate imaging, work up, reassurance, therapeutic options and appropriate follow up, for patients presenting with:
- Mastalgia
- Nipple discharge
- Breast cyst
- Fibroadenoma
- Outline the diagnostic evaluation of a male presenting with a breast mass including detailed history and physical, appropriate work up and imaging, and management options.
- Outline the diagnostic evaluation of a patient presenting with a strong family history of breast cancer and identify possible genetic predisposition syndromes.
- Demonstrate knowledge of the incidence and death rates for breast cancer in the USA.
- Demonstrate knowledge of the AJCC staging system for breast cancer.
- Demonstrate knowledge of the NCCN guidelines for management of benign and malignant breast disease.
- Describe the relative and absolute contraindications to breast conservation therapy.
- Demonstrate basic knowledge of breast reconstruction options following mastectomy and their timing.
- Interpret predictive and prognostic information and its implications on local and systemic therapies, including timing of therapies (neoadjuvant vs. adjuvant).
- Describe the indications for sentinel lymph node biopsy and complete axillary dissection.
- Describe the algorithm for identification of sentinel node biopsy, including the risks and benefits of radiolabeled dye, blue dye, and the 10% rule.
- Collaborate with health care professionals in a multidisciplinary approach to breast disease.
Skill objectives
In addition to the previous objectives, by the completion of the third clinical year, the general surgery resident should be able to:
- Communicate effectively and demonstrate caring and respectful behaviours when interacting with patients and their families.
- Counsel and educate patients and their families under the guidance of faculty.
- With appropriate supervision and assistance, perform basic office procedures including:
- Punch biopsy of the skin
- Cyst aspiration
- Seroma/Hematoma aspiration or drainage
- With appropriate supervision and assistance, demonstrate basic operative skills including:
- Patient positioning for breast and axillary surgery
- Injection of blue dye and appropriate duration of massage
- Consideration of incision placement based on imaging and anatomy
- Skin incision
- Raise skin flaps for mastectomy and lumpectomy
- Removal of breast from chest wall in mastectomy
- Parenchymal dissection in lumpectomy
- Identification of sentinel lymph nodes
- Closure of breast and axillary wounds
- Drain placement