Surgery Rotation

IM Surgery Rotation Curriculum

Program Director: J. Romero MD FACS

Surgery Rotation Educational Goals & Objectives

Surgeons provide continuing care for patients with a myriad of surgical and psychosocial problems. During many patient encounters, the focus is on the diagnosis and treatment of illness. Not infrequently, this endeavor involves consultation with a variety of specialties and review of the risks and benefits of surgical intervention. As such, it is important for residents to be exposed to common surgical disease processes as well as recognize the unusual disease or common disease presenting in an unusual fashion. The Surgery rotation will provide the first year resident with an opportunity to learn normal and abnormal anatomy, become familiar with common surgical questions encountered in internal medicine, and facilitate an understanding of commonly encountered issues in outpatient pre- and postoperative care. The goal of the rotation is to help the resident understand and be able to educate their patients on the evaluation and treatment of surgical disease in the outpatient setting.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients in the course of evaluating and treating surgical disease.

II. Residents will demonstrate the ability to take a pertinent history and perform a focused physical exam. PGY1s should be able to differentiate between stable and unstable patients and elicit the following historical details:

• Cardiovascular risk factors
• Functional status
• Nutritional status
• Prior surgeries
• Pulmonary risk factors

PGY2-3 residents should begin to recognize the contribution of comorbidities and medications to a patient’s operative risk and risk for postoperative complications.

III. PGY1 residents should be able to characterize the following physical findings:

• abdominal distention, anatomic landmarks for procedures, signs of arterial insufficiency, ulcers (arterial, decubitus, venous stasis, and neuropathic)

PGY2 residents should recognize how these findings may present more subtly in the context of comorbidities.

PGY3 residents should be able to do a brief exam focused on pertinent positives and negatives that reflects their understanding of disease.

IV. All residents will understand the indications, contraindications, complications, limitations, and interpretation of following procedures, and become familiar with the safe and effective use of procedures they are able to perform on rotation, which may include:

• drain removal, dressings/wound management, incision and drainage of superficial abscesses, local anesthetic administration, anoscopy.

Medical Knowledge

I. PGY1 residents will develop an understanding of normal basic anatomy and physiology as it pertains to surgical disease. PGY2 residents will recognize abnormal anatomy and understand the pathophysiology of surgical disease. PGY3 residents will understand the interplay between surgical disease and a patient’s underlying comorbidities.

II. Residents should understand the natural history of surgical disease and the expected outcome if a condition is observed, treated medically, or treated surgically. PGY1 residents will develop an initial approach and PGY2s a more complete approach to diagnostic and treatment plans for the following conditions commonly cared for by general surgeons in outpatient settings:

• Abscesses and cysts
• Bariatric and metabolic disorders that have surgical approaches
• Breast benign and malignant disorders
• Colon cancer
• Gallstones and biliary colic
• Gastric ulcers
• Hemorrhoids and perianal issues
• Thyroid masses and other endocrine disorders including tumors, hyper- and hypofunction
• Wounds
• Ulcers

PGY3 residents will understand and weigh the impact of implicit bias in diagnostic and treatment plans.

III. PGY1 residents will understand the indications for ordering, appropriate use, and interpretation of basic laboratory and imaging studies in routine clinic patients and to prepare for surgery.

PGY2 residents will understand how to best use ancillary studies:

• To triage patients with more acute conditions
• To further evaluate complex surgical patients when the diagnosis is unclear

PGY2-3 residents will understand how to use ancillary testing in the context of patient comorbidities and how to incorporate pretest probability of disease

IV. All residents will become familiar with some aspects of postoperative care, including drain and suture removal and dressing changes.

V. All residents should become fluent in social issues relevant to undergoing surgery, including understanding the concepts of informed consent and power of attorney and the impact of social determinants of health on care.

Practice-Based Learning and Improvement

I. All residents should be able to access current national guidelines to apply evidence-based strategies to patient care.

II. PGY2 residents should develop skills in evaluating new studies in published literature.

III. PGY3 residents should adapt a practice approach that reflects consideration of current literature.

IV. All residents should participate in case-based therapeutic decision-making

V. All residents should respond with positive changes to feedback from members of the health care team.

Interpersonal and Communication Skills

I. All residents must demonstrate organized and articulate electronic and verbal communication skills that build rapport with patients and families and provide timely documentation in the chart.

II. All residents should understand and comply with HIPPA with respect to use of health information.

III. PGY1 residents must learn to appreciate the impact of surgery on a patient’s quality of life and learn the essential elements of informed consent. PGY2s must learn to help patients and their families make decisions for or against surgical intervention.

PGY3s must learn to lead discussions with patients and families in contentious situations.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. All residents should be able to educate patients and their families in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.

Systems-Based Practice

I. PGY1 residents must have a basic understanding that their diagnostic and treatment decisions involve cost and risk and affect quality of care.

II. PGY2 residents should be able to explain alternative therapies and their costs, risks, and benefits.

III. PGY3 residents should understand the impact of insurance and social determinants of health on treatment options and quality of care.

Teaching Methods

I. Supervised patient care in the outpatient setting.

• Residents will initially be directly observed with patients to facilitate the acquisition of excellent history taking and physical exam skills.
• As residents become more proficient, they will interact independently with patients and present cases to faculty.
  • Initial emphasis will be on diagnosis and basic management.
  • When residents have mastered these skills, focus will be on medical decision-making, and residents will work with supervising physicians to finalize a care plan.

II. Conferences

• Specialty-specific didactics

III. Independent study

• Journal and Textbook reading
  • Sabiston
  • Schwartz
  • Greenfield
  • American Journal of Surgery
  • Journal of the American College of Surgeons
• Electronic resources
  • American College of Surgeons Resident Resources
  • Pain management and addiction
  • SCORE (American Board of Surgery)
  • Up to Date
  • Clinical Key

Evaluation

I. Verbal mid-rotation individual feedback

II. 360 Evaluation (biannual)

III. Attending written evaluation of resident at the end of the month based on rotation observations and chart review.

Rotation Structure

I. Residents should contact the surgery attending the day prior to determine start time and location.

II. Residents will spend their time in surgery clinic to achieve the above educational goals.

• Rotations are a “hands-on” learning experience. Residents will be involved in discussion of patient presentation, differential diagnosis, decision for or against surgical intervention, and patient follow up.
• When possible, the same resident should see the same patient if they return during the rotation pre- and postoperatively.
• Case-based learning is most effective. Nightly reading/study can serve as a review of daily patient care during the rotation.
• Residents may be asked to do focused literature searches or presentations during the course of the rotation.
• When doing outpatient consults, ensure the resident understands the question asked and provides a concise answer.

III. Hours worked must be consistent with ACGME requirements and are subject to approval by the Program Director.

IV. Residents have specialty-specific didactics and required IM clinic and should be excused in a timely fashion to attend.