Family Medicine Residency Program

Curriculum for

SURGERY

Introduction

This is a two blocks (4 weeks each block) rotation for the first year resident under the supervision of the department of surgery at SJGH.  

Goals

1. Resident will be able to identify and evaluate emergent and non-emergent surgical conditions in the primary care setting, with timely and appropriate surgical referral.
    
2. Residents will acquire the clinical knowledge and skills to assist the surgeon in the assessment and management of patients in the pre-operative and post-operative period.
    
3. Residents will develop competent psychomotor skills necessary for assisting major surgery in the operating room under strict aseptic conditions.
    
4. Residents will learn how to perform outpatient surgical procedures, for example: repair of lacerations, biopsy of superficial lesions, incision and drainage, fine needle aspiration, and manage simple wounds and burns.

Objectives

1. The resident will be able to diagnose and manage the problems listed below under the supervision of the surgical Attending:  
    
   1. Acute GI bleeding
   2. Breast pathology
   3. Colon cancer
   4. Hernias
   5. Benign anal disease
   6. Peripheral vascular disease
   7. Pneumothorax
   8. Hiatal hernia
   9. Thyroid nodules
   10. Peptic ulcer disease
   11. Acute appendicitis
   12. Acute bowel obstruction
   13. Acute ischemic bowel
   14. Acute pancreatitis
   15. Acute cholecystitis
   16. Acute diverticulitis
   17. Acute peritonitis
   18. Acute volvulus
   19. Acute Intussusception
        
2. The resident will be able to list the pathophysiology of the GI tract, which includes:
    
   1. Biliary tract
   2. Pancreas
   3. Spleen
   4. Stomach
   5. Small and large bowel
       
3. The resident will be able to identify the pathophysiology of vascular disease, which includes:
    
   1. Peripheral vascular disorder
   2. Intracranial arterial stenosis (Carotid and vertebral disease)
   3. Aortic and abdominal aneurysm
       
4. The resident will be able to identify commonly encountered hernias, which include:
    
   1. Direct and indirect inguinal hernia
   2. Femoral hernia
   3. Ventral hernia
       
5. The resident will be able to evaluate and manage the fluid, electrolyte and metabolic needs of the surgical patients:
    
   1. Caloric needs for optimal wound healing
   2. Indications and difference of commonly used IV solutions
   3. Indications for various blood components
   4. Indications for hyperalimentation - the resident will also be able to write total parenteral nutrition orders at the end of this rotation.
       
6. The resident will be able to list the important factors that influence normal wound healing
    
7. The resident will be able to order appropriate postoperative care along with other specialtyhospital personels such as dietitian, physical therapist, occupational therapist and respiratory therapist, which include:
    
   1. Fluid management
   2. Nutrition needs
   3. Ambulation
   4. Wound care
   5. Pain management
   6. Pulmonary care
   7. Deep vein thrombosis - prophylaxis, diagnosis and treatment
       
8. The resident will be able to select the appropriate diagnostic tests for evaluation of common surgical conditions, with consideration of costs, discomfort and patient’s preference:
    
   1. Plain X rays
   2. Ultrasound
   3. CT Scan
   4. Conventional angiogram and CT angiogram
   5. MRI and MRA
   6. HIDA Scan
       
9. The resident will be able to list the basic principles of operative surgery, aseptic techniques,hemostasis, suture material and indications for postoperative drains.
    
10. The resident will be able to identify and manage common surgical complications:
     
    1. Pre-operative antibiotic prophylaxis
    2. Post- operative pulmonary complication
    3. Prophylaxis of Deep vein thrombosis and pulmonary embolism
    4. Post-operative hemorrhage
    5. Post-operative ileus
        
11. The resident will be able to list different treatment options for deep vein thrombosis, varicoseveins, chronic venous stasis and ulcers management.
     
12. The resident will be able to manage acute trauma under supervision at the emergencydepartment of SJGH.
     
13. The resident will be able to discuss informed and written consents with the patients before surgery.
     
14. At the end of the rotation, the resident is able to first assist in common surgical procedures.

Implementation

This is an 8 week rotation (in two blocks) for the first year resident who will be working under the supervision of Board-certified surgeons at SJGH. This rotation includes lecture series on various surgical topics, as well as hands on experience in the operating room.

Evaluation

The teaching Attending will provide ongoing and regular feedback throughout the rotation to advise the resident of the status of his/her performance and initiate options for improvement where and when necessary. There will be a scheduled, specific focused meeting with the Attending and the resident at the end of the rotation to discuss the overall performance of the resident and his/her strengths and weaknesses. At the end of the rotation, the teaching attending will complete a formal evaluation form, which is an outcome-based measurement of the following:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. (Objectives 1-14)
    
2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. (Objective 1-12, 14)
    
3. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. (Objective 8,9,11)
    
4. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. (Objective 13)
    
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. (Objective 14)
    
6. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. (Objective 7)

Methods of evaluation

The resident will be evaluated by the surgical Attending.

1. Formative evaluation:
    
   1. The surgical Attending will give continuous and meaningful feedback to the resident for his/her performance.
       
   2. Methods: Portfolio, checklist, specific patient, exam oral, chart review, MCQ and global rating.
       
      1. The resident will keep a log of all surgical patients (medical record number, gender, age, diagnosis, and Primary Care Provider, whom he/she has involved. The log will be kept in the resident’s permanent folder in the residency office. (Portfolio). The log will be reviewed timely in the scheduled quarterly resident review of the 1st year resident.
          
      2. The resident will keep a log of all surgical procedures that he/she has involved. The log will reflect the degree of involvement of the resident (Observe, assist, or perform under supervision). In addition, it will contains the evaluation of the competency of the resident in the specific procedure by the Attending surgeon. The log will be kept in the resident permanent folder. (Portfolio)
          
      3. Resident’s performance will be assessed continuously during daily surgical round and in the operating room. (Specific patient, exam oral)
          
      4. The resident initial and daily progress notes will be examined by the surgical Attending. (Chart review)
          
2. Summative evaluation:
    
   1. The surgical Attending will complete a formal evaluation form at the end of the Rotation. (Global rating)
       
   2. The result of the resident annual in-training exam in surgery category will be evaluated by the resident Faculty advisor who will discuss with the resident for improvement if necessary. (MCQ)

Each resident will evaluate the teaching/supervising Attending at the end of the rotation, as well as, will evaluate the curriculum of the rotation itself. The Attending evaluations are done anonymously. (Global rating)

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