HO III - Surgical Oncology

Specific Educational Goals and Education

Level: PGY-3

Service: Surgical Oncology

Supervision: PGY -3 → PGY -5 → Attending
All management decisions will be discussed with the 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. Schwartz's Principles of Surgery
    2. SCORE curriculum modules
  2. Conferences
    1. Wednesday Resident Educational Curriculum
    2. Multi-disciplinary Lung Tumor Board- Tuesday
    3. Multi-disciplinary Breast Tumor Board- Wednesday
    4. Multi-disciplinary Gastrointestinal Tumor Board- Thursday

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:
    1. Gastric resection
    2. Colon resection
    3. Pancreatic resection (Whipple Procedure)
    4. Mastectomy
  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 disease.
  8. Perform colostomies, colostomy closures, and bowel anastomoses of all types.
  9. Demonstrate proficiency in the use and interpretation of operative and endoscopic ultrasonography.
  10. Perform, with appropriate supervision, major resections in neck, chest, abdomen, and extremity, including complex operative procedures (, Whipple procedures, segmental and lobar hepatic resections).
  11. Demonstrate proficiency in endoscopic ultrasonography for detection of hepatic metastases and depth of invasion of colorectal lesions.
  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 disease.
  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.  Serve as assistant to the primary surgeon during operations of the esophagus, stomach, small intestine, colon, and anorectal.
  18. 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)
  19. Provide follow-up care to the surgical patient in the outpatient clinic or surgical office.
  20. Interpret the following in coordination with attending radiologists and staff; upper GI series, barium enema, and abdominal ultrasound and CT scans.
  21. Evaluate and institute management of abdominal wound problems, including; infection, evisceration, fasciitis, and dehiscence.
  22. Perform history and physical examination specifically focused on liver and biliary system.
  23. Select and interpret appropriate laboratory and radiologic evaluations in the work-up of the jaundiced
  24. Perform uncomplicated hepatobiliary surgery under supervision, such as cholecystectomy, both laparoscopic and open, with operative cholangiography.
  25. Assist in more advanced hepatobiliary operations.
  26. Perform history and physical examination focused on the pancreas.
  27. Select and interpret appropriate laboratory and radiologic examinations in evaluation of pancreatic disease
  28. Assist in perioperative management of patients undergoing pancreatic surgery.
  29. Participate in a multidisciplinary tumor board

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, demonstrate the ability to surgically manage diseases of the breast, and understand the advancements of minimally invasive and conservative breast surgeries.

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. Embryologic abnormalities of the GI tract, including:
      1. Strictures
      2. Stenoses
      3. Webs
      4. Atresias
      5. Duplications
      6. Malrotations
    2. Neoplasia of the GI tract
    3. Causes of GI obstruction
    4. Causes of GI hemorrhage
    5. Causes of GI perforation
    6. Management of intestinal ostomies
  3. Discuss some of the more common diseases of the esophagus in elderly patients, to include:
    1. Motility disorder
    2. Tumors (benign and malignant)
  4. 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
  5. Describe the anatomy of the omentum and its role in responding to inflammatory processes.
  6. 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
  7. 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
  8. List the factors that prevent healing of a fistula.
  9. 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
  10. Analyze the factors affecting the decision to select a minimally invasive approach (as opposed to an open surgical approach) for a particular clinical problem.
  11. 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
  12. 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.
  13. Additional Laparoscopic Procedures
    1. 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
    2. Summarize other intra-abdominal laparoscopic procedures currently being performed, including:
      1. Adrenalectomy
      2. Gastrectomy
      3. Splenectomy
      4. Donor nephrectomy
  14. Describe the anatomy of the liver and biliary system, including commonly found variations.
  15. Discuss the enterohepatic circulation of bile.
  16. Outline the work-up and differential diagnosis of the jaundiced patient.
  17. Discuss various types of liver cysts (echinococcal or hydatid, nonparasitic) and the appropriate management of each.
  18. 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
  19. 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. Benign biliary stricture
  20. Describe the anatomy of the pancreas, including regional vascular anatomy.
  21. 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
  22. 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
  23. 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
  24. 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
  25. Explain the diagnosis and management of pancreatic ascites.
  26. Apply clinical screening for common malignancies. Recognize typical presentations and clinical manifestations for different types of neoplasms.
  27. Describe the stimuli for and the biologic events in angiogenesis and the potential therapeutic implications there of.
  28. Discuss the known facts relative to tumor suppressive genes and the implications of mutations.
  29. Stage specific neoplasms both clinically and pathologically, including the tumor, nodes, and metastasis system (TNM).
  30. Relate tumor staging to prognosis.
  31. Describe differences in presentation, treatment, and outcomes for malignancy in older patients.
  32. Compare each applicable treatment modality to the prognosis for tumors within the scope of general surgery.
  33. Apply post-treatment screening/surveillance for common malignancies.
  34. Discuss the known facts relative to tumor recurrence after local resection of a primary lesion of the breast and colon with regard to survival.
  35. Identify margins of resection and how this relates to local recurrence.
  36. Describe the indications for and actions of pharmacologic support in the post-operative stats.
  37. Describe the indications and means for implementing nutritional support in the pre- and post-operative cancer patient.
  38. Explain the fundamental principles of radiation oncology and detail its application as a primary therapy for the treatment of selected benign and malignant lesions.
  39. Summarize the indications and appropriate modalities for adjuvant therapy within the scope of general surgery, including chemotherapy, radiation therapy, immunotherapy, and gene therapy.
  40. Describe radioimmunoguided surgery (RIGS) and its clinical applications.
  41. Explain the rationale and methodology employed in lymphatic mapping and sentinel node biopsies along with the expected level of positive findings.
  42. Understand the surgical options for venous access and oncologic care, and their risks/complications.
  43. Describe the criteria and necessary procedures for intraoperative monitoring of cardiovascular and pulmonary functions of the cancer patient.
  44. Analyze and explain an holistic approach to the treatment of patients with cancer.
  45. Analyze the medical preparation of patients for cancer surgery to include the correction of metabolic and nutritional deficits.
  46. Indicate the potential alterations in pulmonary function in the elderly patient which may affect pre-operative preparation and post-operative management.
  47. Identify the indications of anticipated need in elderly patients for:
    1. Post-operative urinary tract decompression
    2. Nutritional support
    3. Thromboembolism prophylaxis
  48. Define and apply the criteria for palliative versus curative treatment plans.
  49. Analyze and explain the rationale for combined adjuvant modalities in the prevention and treatment of cancer recurrence.
  50. Apply proper clinical and demographic data to the tumor registry.
  51. Outline the indications for and initiate requests for appropriate consultation.
  52. Demonstrate a working knowledge of prior research milestones, current research efforts, and cancer research methodology.
  53. 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
  54. 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
  55. 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
  56. 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.
  57. 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?
  58. 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
  59. 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
  60. 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
  61. 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. Cushing's syndrome
    2. Exogenous hypercortisolism
    3. Chronic alcohol abuse
    4. Chronic intake of self-administered arthritis pills
  62. 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
  63. 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
  64. 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
  65. 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
  66. Critique the role of the following developments in the surgical management of endocrine problems:
    1. Localizing modalities (metaiodobenzylguanine [MIBG], sestamibi, selective venous sampling, intraoperative tumor localization, rapid parathyroid hormone [PTH] assays)
    2. Diagnostic assays (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:

Receptiveness to faculty instruction and feedback
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 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.
  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.