UNIVERSITY OF MANITOBA DEPARTMENT OF SURGERY RESIDENCY PROGRAM BLUE BOOK

Transcription

1 UNIVERSITY OF MANITOBA DEPARTMENT OF SURGERY RESIDENCY PROGRAM BLUE BOOK

2 Table of Contents TABLE OF CONTENTS Section 1: Administrative & Organization 1.1: Goals and Objectives 1.2: Administrative Structure 1.3: Educational Structure/Organization 1.4: Curriculum 1.5: Program Teaching Sites 1.6: Principles of Surgery Training 1.7: Chief/Senior Administrative Resident Section 2: Learning Objectives (Mandatory Rotations) 2.1: General Surgery 2.2: General Surgery A-Service 2.3: General Surgery B-Service 2.4: General Surgery Community Surgery 2.5: General Surgery Gold Service: Trauma & Acute Care 2.6: General Surgery Green Service: Surgical Oncology 2.7: General Surgery Orange Service: General & Hepatobiliary Surgery 2.8: Anatomy 2.9: Critical Care 2.10: Emergency 2.11: Endoscopy 2.12: Internal Medicine 2.13: Pediatric Surgery 2.14: Vascular Surgery Section 3: Learning Objectives (Elective Rotations) 3.1: Anesthesiology 3.2: Cardiac Surgery 3.3: Gastroenterology 3.4: Neurosurgery 3.5: Orthopedic Surgery 3.6: Plastic Surgery 3.7: Radiology 3.8: Surgical Infectious Diseases 3.9: Thoracic Surgery 3.10: Urology Section 4: Other Components of Program 4.1: Academic & Scholarly 4.2: Career Planning 4.3: Evaluation of Faculty 4.4: Evaluation of Resident Performance 4.5: Evaluation of Services/Rotations 4.6: Master of Science in Surgery Program 4.7: Research Activities 4.8: Resident Resources 4.9: Stress Management Page 0.0.1

3 Table of Contents Section 5: Forms Christmas/New Year s Request Form Education Leave Request Form General Surgery CanMEDS Anatomy Evaluation Form General Surgery CanMEDS Evaluation From General Surgery CanMEDS Mid-Rotation Evaluation Form Vacation Request Form Page 0.0.2

4 Section 1: Administrative & Organization

5 Administrative & Organization Goals and Objectives 1.1: GOALS AND OBJECTIVES DEFINITION OF GENERAL SURGERY The specialty of General Surgery embraces the principles and techniques of safe, effective, ethical and compassionate care of the whole person of any age and is the parent of all surgical specialties. The general surgeon is an eclectic specialist whose practice involves the alimentary tract, trauma and critical care, endocrine and breast diseases, cancer surgery and endoscopy. By virtue of training, special interest or circumstances, the practice of general surgery may be narrowly focused or may encompass diseases or injuries affecting virtually any body system. General surgical practice includes expertise in communication and collaboration, teaching and research, health care management and advocacy and continuing professional development. OVERALL GOAL OF THE PROGRAM Upon completion of training in the General Surgery Residency Training Program at the University of Manitoba, the resident is expected to be a competent specialist capable of assuming a consultant s role in general surgery (see Objectives of Training and Specialty Training Requirements in General Surgery RCPSC). As the scope of General Surgery is very broad and the types of practice will vary considerably, the Program allows the resident to pursue one of the following career paths: Academic surgery Community surgery In order to achieve competency in General Surgery, the resident must achieve the following: Knowledge and expertise in clinical and operative management of diseases of the alimentary tract, breast and endocrine systems, trauma and critical care, general surgical oncology and ambulatory care Mastery of technical skills of open and minimal access abdominal, endocrine, breast, trauma, soft tissue and abdominal wall surgery and endoscopy Effective clinical judgment and decision-making in managing general surgical problems based on sound principles and fundamentals The Program emphasizes that the resident must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to the practice of General Surgery, including research methodology and data presentation and analysis. The General Surgery Residency Training Program at the University of Manitoba has developed and distributed specific learning objectives for each rotation/educational experience within the Program. The learning objectives are functional for the residents and the teaching faculty. Furthermore, the learning objectives are reflected in resident evaluations and in the planning and organization of the Program. The Program embraces the Royal College of Physicians and Surgeons of Canada CanMEDS competencies of the specialist physician and these are reflected in the overall and rotation-specific learning objectives (see diagram below). Page 1.1.1

6 Administrative & Organization Goals and Objectives Page 1.1.2

7 Administrative & Organization Administrative Structure 1.2: ADMINISTRATIVE STRUCTURE PROGRAM DIRECTOR The Program Director is responsible for the overall conduct of the General Surgery Residency Training Program (also referred to as the Program in this document). The Program Director is responsible to the Head of the Department of Surgery, the Director of Postgraduate Surgical Education and the Associate Dean of Postgraduate Medical Education of the University of Manitoba. The Program Director, assisted by the General Surgery Postgraduate Committee is responsible for: Development and operation of the Program such that it meets the standards for accreditation by the Royal College of Physicians and Surgeons of Canada (RCPSC) Selection of candidates for admission to the Program Evaluation and promotion of residents in the Program Maintenance of an appeal mechanism for residents Provision of counselling and career planning for residents Intervention to deal with resident problems such as those related to stress Review (resident opinion taken into consideration)) of the quality of the educational experiences and the resources available, including: o Assessment of each component of the Program to ensure that the learning objectives are being met o Assessment of resource allocation o Assessment of teaching o Faculty evaluation The Program Director advocates for the resident and maintains an open-door policy with respect to resident concerns or problems. The resident is encouraged to bring any matters of concern to the Program Director for timely intervention. Matters that cannot be adequately addressed by the Program Director are referred to the appropriate parties for definitive management. The resident can choose an individual other than the Program Director to advocate on his/her behalf. There is a Program Coordinator, responsible to the Program Director in each institution participating in the Program. There is active liaison between the Program Director and the Program Coordinators. GENERAL SURGERY POSTGRADUATE COMMITTEE The General Surgery Postgraduate Committee (Committee) assists the Program Director in planning, organization and supervision of the Program. The Committee includes the Program Coordinators, Service Chiefs, representatives from each major component of the Program and resident representatives from each level of training elected by their peers. The Committee meets every two months (five times per year) and minutes are kept. During the meetings, faculty/resident interaction and discussion take place in an open and collegial atmosphere. SURGICAL EDUCATION OFFICE The Surgical Education Office functions as the headquarters of the General Surgery Residency Training Program. The office of the Coordinator-Surgical Education Programs and the secretarial and support staff are located there. The resident should contact the Surgical Education Office if he/she is encountering any difficulties and the Coordinator (or designate) will assist in facilitating a timely resolution of the problem(s). Page 1.2.1

8 Administrative & Organization Educational Structure/Organization 1.3: EDUCATIONAL STRUCTURE/ORGANIZATION The General Surgery Residency Training Program at the University of Manitoba is organized into mandatory and elective surgical and non-surgical rotations whereby the resident must acquire the requisite knowledge, clinical and technical skills and attitudes and must integrate all of the CanMEDS roles to become a specialist general surgeon. Each resident enrolled in the Program has an equal opportunity to take advantage of those elements of the Program best able to meet his/her educational needs. Furthermore, the Program encourages teaching and learning in an environment which promotes resident safety and is free of intimidation, harassment and abuse. The Program is structured for the resident to achieve the learning objectives as follows: COGNITIVE (KNOWLEDGE) The resident is encouraged to: Maintain a regular program of reading selected textbooks and journals Attend academic/educational sessions, including the General Surgery Academic Half-Day (mandatory) Attend the monthly General Surgery Journal Club (mandatory) Utilize the amenities of the General Surgery resource rooms Attend scientific meetings Arrange for an attending surgeon to be his/her mentor PSYCHOMOTOR (CLINICAL AND TECHNICAL SKILLS) Clinical Skills During the years of training in the Program, the resident is immersed in the clinical setting, developing and improving his/her skills in disease recognition and in appropriate investigation and management of general surgical disorders. He/she develops the ability to apply knowledge of anatomy, physiology and pathology to the clinical situation and to treat the whole patient. He/she is given increasing professional responsibility according to his/her level of training, ability and experience. The clinical learning objectives and expectations depend on the resident s level of training as follows: During the first three years in the Program the resident is participates as a member of the general surgical teaching units. The resident gains experience through specific unit assignments, including: Emergency Department where the PGY-1, PGY-2 or PGY-3 resident learns resuscitation, assessment and management of patients with surgical emergencies and discuss these with a more senior resident and/or attending surgeon Surgical Clinic where the PGY-1, PGY-2 or PGY-3 resident assesses new patients with elective or urgent surgical illness and assess postoperative patients with respect to their recovery and progress and discusses this with a more senior resident and/or attending surgeon Hospital Ward where the PGy-1, PGY-2 or PGY-3 resident learns the preoperative and postoperative management of hospitalized patients and discusses this with a more senior resident and/or attending surgeon Page 1.3.1

9 Administrative & Organization Educational Structure/Organization Technical Skills It is expected that the General Surgery resident will develop technical skills (including intraoperative decision-making and surgical judgment) in a graded manner. Ultimately the resident is expected to perform general surgical procedures competently, safely and independently. Some of the more complex surgical procedures may require further training beyond the five-year Program. The General Surgery resident should develop basic technical skills during the first two years of the Program as follows; Handling of the scalpel (power/precision) Creation and closing of surgical incisions Mastering knot-tying skills and understanding suture materials Mastering the principles of gentle tissue handling Mastering the principles of surgical assisting Mastering surgical stapling skills and understanding stapling devices Mastering the techniques pertaining to hemostasis Comprehending the techniques of intestinal and vascular anastomosis Understanding the principles of surgical drains Mastering open /laparoscopic general surgical procedures appropriate for his/her level of training The basic technical skills are taught in the Surgical Skills Courses scheduled during the Program (see Academic and Scholarly Content of the Program), and in the clinical setting. Some of the basic skills, such as knot-tying are mastered with practice outside the clinical setting. The General Surgery resident develops mastery of the major general surgery procedures (open, minimal access and endoscopy) during the more senior years in the Program. During the final year of training, the General Surgery resident should progress to performing substantial parts of most general surgical procedures independently or with assistance only and should be able to teach more junior residents the less complex technical procedures. The General Surgery resident must maintain a surgical/endoscopic procedure log during his/her training. The log assists the resident for certification/credentialing purposes and assists the Program Director in evaluating the resident s progress and in ensuring that he/she has attained an increasing level of professional responsibility. The log is compiled and maintained in an online format. The resident must write preoperative/operative notes on all patients on whom he/she has operated. Furthermore, the resident who performs the substantial part of the operation must dictate the operative report in a timely manner. AFFECTIVE (ATTITUDE/PROFESSIONAL CONDUCT) The General Surgery Training Program at the University of Manitoba requires that the resident attain and demonstrate the learning objectives with respect to attitude and professional conduct. These include: Communication skills Collaboration with other health care workers Management skills to balance patient care, learning needs, outside activities and personal life Health advocacy to improve individual and societal health Scholarly activities, including teaching and research Professional/ethical conduct The affective objectives are met through role modeling within the Program and through academic and educational seminars and courses. Page 1.3.2

10 Administrative & Organization Educational Structure/Organization SERVICE/EDUCATION RELATIONSHIP The success of the General Surgery Residency Training Program relies on the understanding by the resident and the faculty that there are educational and service components which must interact harmoniously. The Program strongly supports the concept that resident education is paramount. However, surgical education is in many ways dependent on service responsibilities. At no time will a resident s educational schedule be disrupted or altered to satisfy service requirements unless the move is advantageous to the resident s education and the resident agrees to it. The General Surgery Residency Training Program Academic Half-Day takes place on Wednesday afternoon. All General Surgery residents are excused from clinical/service duties during this time (protected) and attendance is mandatory. If the resident at any time feels that his/her educational activities are being infringed upon in the interest of service, he/she should discuss this with the Chief of the service, the Program director or the Chief resident. ON-CALL DUTIES On-call schedules are arranged by the Chief resident in General Surgery. Presently the on-call frequency averages one night in three (maximum). This frequency corresponds to the principles established by an agreement between the Professional Association of Residents and Interns of Manitoba (PARIM) and the Winnipeg Regional Health Authority (WRHA). When a resident is on vacation the on-call schedule is modified accordingly without increasing the average frequency of on-call of the remaining residents. Occasionally a resident on a rotation without on-call duties is requested by the Chief resident in General Surgery to assist with on-call duties (maximum frequency one night in seven) on a service where one of the residents is on vacation or absent for other reasons. This must occur on a voluntary and collegial basis. The Program strongly supports the concept of the resident leaving the service early the day after being oncall (post-call). Appropriate patient hand-over must be completed, urgent duties must be completed and co-residents must be notified. MOONLIGHTING Although moonlighting is not prohibited, it is not encouraged. Scholarly and recreational pursuits by the resident are more important. Moonlighting probably interferes with the resident s educational activities and is generally felt to be counter-productive. The Program Director will prohibit the resident from moonlighting if there is a concern with respect to his/her academic performance (CAGS exam results, for example). Page 1.3.3

11 Administrative & Organization Curriculum 1.4: CURRICULUM The General Surgery Residency Training Program at the University of Manitoba consists of five years of general surgical training (optional six years with the Master of Science Degree in Surgery). The Program is organized such that the resident is given increasing professional responsibility, under appropriate supervision, according to his/her level of training, ability and experience on clinical rotations. The academic and scholarly aspects of the Program complement the resident s clinical experience and prepare the resident to fulfill all of the roles of the specialist General Surgeon (see Objectives of Training and Specialty Training Requirements in General Surgery RCPSC). Evaluation of the resident s performance is made regularly, and this contributes to the final assessment to sit the certification examination in General Surgery. The first two years of the Program are structured as Principles of Surgery (formerly called Core Training in Surgery), which consists of broad-based clinical rotations in surgical and non-surgical areas and Core Surgery lectures which supplement the clinical experience and follow the RCPSC objectives (see Objectives of Core Training in Surgery and Outline of the Contents for the Examination on the Principles of Surgery). It is expected that the General Surgery resident will write the Principles of Surgery Examination (POS) during the second year of training (PGY-2). The third and fourth years of the Program consist of general surgical experience and exposure to endoscopy, vascular surgery and pediatric surgery. Community surgery and other electives are offered as well. The resident s curriculum is designed to meet his/her individual requirements for future surgical practice. Those residents interested in an academic career may choose the Master of Science Degree in Surgery Program for an additional year of research experience (after PGY-2 or after PGY-3). During the final year in the Program, the resident functions as the Senior/Chief resident, where he/she is entrusted with the responsibility for preoperative, operative and postoperative care, including the most difficult general surgical problems. The Senior/Chief resident is in charge of a general surgical unit and is directly responsible to the attending staff surgeons in the unit. Page 1.4.1

12 Administrative & Organization Program Teaching Sites 1.5: PROGRAM TEACHING SITES Several hospitals participate in the General Surgery Residency Training Program at the University of Manitoba. These include: Major teaching hospitals Community Hospitals Other MAJOR TEACHING HOSPITALS There are two major teaching hospitals in Manitoba and these provide extensive clinical educational experience for the resident. Health Sciences Centre This is Manitoba s largest health care complex and functions as the major referral centre for trauma and acute surgical illness (General Hospital). It is the major referral centre for pediatrics and pediatric surgical illness (Children s Hospital). The general surgery sites at the Health Sciences Centre include: General Hospital Trauma and Acute Care Service (Gold) Provides training in trauma and acute care surgical management Attending surgeons are on-site on a twenty-four hour basis Formal walk rounds with the attending surgeon Ambulatory clinic experience Hepatobiliary/Gastrointestinal Service (Orange) Major emphasis on gastrointestinal surgery Strong liaison with gastroenterology/endoscopy unit Formal rounds Ambulatory clinic experience Surgical Oncology Service (Green) Major emphasis on head and neck and other malignancies Multidisciplinary management of complex oncology cases Ambulatory clinic and Breast Health Centre experience Liaison with CancerCare Manitoba Children s Hospital Pediatric Surgery Unit Exposure to most major pediatric surgical disorders (except cardiac surgery) Formal rounds and teaching sessions Ambulatory clinic experience St. Boniface General Hospital St. Boniface General Hospital is a major referral centre for complex general surgical problems, excluding multiple trauma. There is a major emphasis on colorectal, breast and minimal access general surgery. The surgical skills laboratory facility is located at St. Boniface General Hospital. Page 1.5.1

13 Administrative & Organization Program Teaching Sites A-Service General Surgery Emphasizes most general surgical disorders Major minimal access general surgery component Major gastrointestinal/colorectal surgery component Major breast surgery component Liaison with endoscopy unit/gastrointestinal bleed team Formal rounds and audit Ambulatory clinic and Breast Health Centre experience B-Service General Surgery Emphasizes most general surgical disorders Major gastrointestinal/colorectal surgery component Liaison with endoscopy unit/gastrointestinal bleed team Formal rounds and audit Ambulatory clinic experience COMMUNITY HOSPITALS Several urban and rural community hospitals in Manitoba allow the General Surgery resident elective training in community general surgical practice. These include: Brandon Regional Health Centre in Brandon, Manitoba Dauphin Regional Health Centre in Dauphin, Manitoba OTHER COMMUNITY HOSPITALS The resident has the opportunity to arrange an elective at one of the following community hospitals: Seven Oaks General Hospital in Winnipeg Victoria General Hospital in Winnipeg Concordia Hospital in Winnipeg OTHER TEACHING SITES Northwestern University Hospital This hospital, located in Chicago, Illinois provides elective training in organ transplantation. Winnipeg Regional Health Authority Breast Health Centre This facility provides a multidisciplinary milieu for the resident to learn the assessment and management of breast disorders Churchill Health Centre This complex, located in Churchill, Manitoba has a liaison with the Northern Medical Unit at the University of Manitoba. The General Surgery resident may be invited (if circumstances permit) by the attending surgeon to accompany him/her to Churchill for training and experience in northern medicine and surgery. Page 1.5.2

14 Administrative & Organization Principles of Surgery Training 1.6: PRINCIPLES OF SURGERY TRAINING During the PGY-1 and PGY-2 the General Surgery resident learns the Principles of Surgery pertinent to general surgical training. This period of training consists of mandatory and elective clinical rotations and a structured lecture series based on the learning objectives for the Principles of Surgery as specified by the Royal College of Physicians and Surgeons of Canada. Training for the Principles of Surgery follows the recommendations of the RCPSC so that the Program Director for the General Surgery Residency Training Program and the General Surgery Postgraduate Committee are responsible for developing the Principles of Surgery curriculum/rotation-specific objectives and for evaluation of the General Surgery resident. During this period of training, the General Surgery resident remains the responsibility of the Program Director for General Surgery. The Director of the Principles of Surgery Training oversees the academic component of core training for residents of all surgical programs. He/she receives input, guidance and support from the individual program directors. It is expected that the General Surgery resident will write the Principles of Surgery Examination (POS) in the PGY-2 academic year. The following reference is important for the resident to review: Objectives of Core Training in Surgery and Outline of Contents for the Examination on the Principles of Surgery (RCPSC) Page 1.6.1

15 Administrative & Organization Chief/Senior Administrative Resident 1.7: CHIEF/SENIOR ADMINISTRATIVE RESIDENT CHIEF RESIDENT There will be a Chief resident nominated by his/her peers and approved by the Program Director for the academic year. The Chief resident will have the authority and responsibility for overseeing the administrative and teaching duties of all residents in the Program, including Senior Administrative residents. All residents report to the Chief resident. The Chief resident reports to the Program Director. CLINICAL RESPONSIBILITIES The Chief resident is assigned to a specific general surgical unit and will oversee the more junior residents in an advisory capacity, including: Assignment of appropriate clinical cases to the more junior residents to encourage graded responsibility in the operating room Assisting the more junior residents in the management of difficult or complex cases The Chief resident assumes overall responsibility for all patients on the general surgical unit with respect to: Investigations and planning of care Preoperative preparation Intraoperative management/operative report Postoperative care/rounds/notes Discharge planning The Chief resident attends the Service Rounds and ambulatory care clinics on his/her assigned service regularly. The Chief resident will take regular on-call duties. ADMINISTRATIVE RESPONSIBILITIES The Chief resident is responsible for the following: Convening of meetings of the residents in the Program to discuss issues of concern Attending the meeting of the General Surgery Postgraduate Committee (or he/she may send a delegate if unable to attend) Ensuring that a resident representative to PARIM council is elected from among the residents in the Program Ensuring that there is resident representation on Program, departmental and faculty committees for matters pertaining to education Ensuring that there is resident representation on hospital committees concerning issues such as audit and mortality review Acting as liaison between the residents in the Program and faculty members for purposes of communication, mediation and conflict resolution Coordination and preparation of the on-call schedules Serving on probation committees Page 1.7.1

16 Administrative & Organization Chief/Senior Administrative Resident Assisting in the approval of conference leave for residents Ensuring that the resident resource rooms and their contents are maintained EDUCATIONAL RESPONSIBILITIES The Chief resident is responsible for the following: Teaching of more junior residents and physicians in training Coordination of orientation of new residents and physicians in training SENIOR ADMINISTRATIVE RESIDENT Final-year residents in the Program on services or at sites remote from the Chief resident are designated Senior Administrative residents. They report to the Chief resident and assist him/her. CLINICAL RESPONSIBILITIES The Senior Administrative resident has the same clinical duties as the Chief resident ADMINISTRATIVE RESPONSIBILITIES The Senior Administrative resident will: Function as the Chief resident if he/she is absent for any reason Maintain regular communication with the Chief resident and discuss issues of concern Prepare the on-call schedules under the supervision of the Chief resident EDUCATIONAL RESPONSIBILITIES The Senior Administrative resident will: Assist in the education of more junior residents and physicians in training Assist in the orientation of new residents and physicians in training Page 1.7.2

17 Section 2: Learning Objectives (Mandatory Rotations)

18 Learning Objectives (Mandatory) General Surgery 2.1: GENERAL SURGERY PREAMBLE The following learning objectives apply generally to any of the rotations/services in General Surgery participating in the General Surgery Residency Training Program at the University of Manitoba. However, each rotation or service has its particular area of subspecialty, expertise or interest, with a greater emphasis on certain aspects of the learning objectives and a lesser concentration on others (e.g. Trauma and Acute Care (Gold) Service; Surgical Oncology (Green) Service). Furthermore, surgical services may change their emphasis, depending on the faculty assigned to the service. GENERAL OBJECTIVES Upon completion of training, the General Surgery resident is expected to be a competent specialist in General Surgery, capable of assuming a consultant s role. The resident must acquire a thorough knowledge of the theoretical basis of General Surgery, including its foundations in the basic medical sciences and research. The resident must demonstrate the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies of the General Surgeon, including gender-related, cultural and ethnic perspectives. SPECIFIC OBJECTIVES At the completion of training, the General Surgery resident will have acquired the following competencies and will function effectively as: Medical Expert General Surgeons possess a defined body of knowledge and procedural skills which are used to collect and interpret data, make appropriate clinical decisions and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date and (whenever possible) evidence-based, ethical and cost-effective clinical practice and effective communication in partnership with patients, other health care providers and the community. The role of the medical expert is central to the function of the general surgeon and draws on the competencies included in the role of communicator, manager, health advocate, collaborator, scholar and professional. At the completion of training, the General Surgery resident will be able to: Function effectively as a consultant, integrating all of the CanMEDS roles to provide optimal, ethical and patient-centred general surgical care Effectively perform a consultation, including the presentation of well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care professional Identify and appropriately respond to relevant ethical issues arising in patient care Effectively and appropriately prioritize professional duties when faced with multiple patients and problems Demonstrate compassionate and patient-centred care Recognize and respond to the ethical dimensions in medical decision-making Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases, etc.) Page 2.1.1

19 Learning Objectives (Mandatory) General Surgery Establish and maintain clinical knowledge, skills and attitudes appropriate to the practice of General Surgery Apply knowledge of the clinical, socio-behavioral and fundamental biomedical sciences relevant to General Surgery Apply lifelong learning skills to implement a personal program to keep up-to-date and enhance areas of professional competence Contribute to the enhancement of quality care and patient safety, integrating the available best evidence and best practices The resident in General Surgery is required to attain sufficient knowledge as follows: Basic/General Areas Surgical Anatomy and Embryology Surgical Physiology Surgical Pathology Clinical Pharmacology o Analgesics; sedatives; anesthetic agents o Respiratory and cardiovascular o Gastrointestinal o Antibiotics o Antineoplastic agents o Antiemetic agents Medical Problems in the Surgical Patient o Preoperative assessment o Preparation for specific operative interventions o Antimicrobial prophylaxis o Anticoagulation and thromboembolic prophylaxis o Corticosteroid management o Diabetes management Conduct of a Surgical Procedure o General principles o Specific operative interventions Postoperative Care o Prevention and treatment of postoperative infections o Management of cardiac/hypertensive complications o Management of postoperative thromboembolic complications o Management of postoperative pulmonary complications o Management of endocrine/metabolic problems (e.g. diabetes) o Management of fluid and electrolyte/renal problems Wound Management and Healing Sepsis and Surgical Infections Hemostasis and Use of Blood Products Epidemiology and Biostatistics Trauma and Thermal Injuries o Metabolic response to critical illness/trauma o Multi-organ dysfunction o Trauma assessment and resuscitation (ATLS principles) o Triage and transport o Airway management in trauma o Shock in trauma o Injuries to the central nervous system o Injuries to the face and jaw o Injuries to the neck o Injuries to the chest/diaphragm/great vessels o Abdominal trauma (including major vascular injuries) Page 2.1.2

20 Learning Objectives (Mandatory) General Surgery o Injuries to the urogenital tract o Musculoskeletal injuries o Injuries to the extremities (vascular; bone; soft tissues) o Burns and other thermal injuries Fluid Management and Acid-Base Problems Metabolic and Nutritional Care Hemodynamics/Oxygen Transport/Shock Transplantatation and Implantation o Immunology and transplantation biology o Specifics of transplantation techniques Cancer o Principles of neoplasia o Diagnosis and staging o Therapeutic options: surgery; chemotherapy; radiation; other o Principles of chemotherapy o Principles of radiation oncology Legal and Ethical Issues in General Surgery Radiology for the General Surgeon o Plain x-rays o Mammography/stereotactic breast biopsy o Contrast studies and interventional radiology o Computerized tomography o Ultrasound o Magnetic resonance imaging o Nuclear medicine studies o Positron emission tomography (PET) Laboratory Medicine for the General Surgeon o Hematology o Biochemistry o Microbiology o GI laboratory studies: esophageal manometry and ph; anorectal manometry o Vascular laboratory studies Specific Disease Entities Skin and Soft Tissue o Pressure sores o Hidradenitis suppurativa o Pilonidal sinus disease o Cysts o Neoplasms, including melanoma and Kaposi s sarcoma Breast o Fibrocystic condition/simple cyst/complex cyst o Fibroadenoma and other benign neoplasms/phylloides tumour o Abscess/mastitis o Nipple discharge o Gynecomastia o Mastodynia o Evaluation of dominant mass/thickening o Atypical epithelial hyperplasia o LCIS/DCIS o Inherited breast cancer o Paget s disease o Invasive breast cancer o Male breast cancer o Breast reconstruction Page 2.1.3

21 Learning Objectives (Mandatory) General Surgery Head and Neck o Lip lesions o Oral cavity lesions o Salivary gland lesions: inflammatory; infectious; neoplastic o Thyroid disorders: goiter; neoplastic;inflammatory o Parathyroid disorders: metabolic; neoplastic Veins and Lymphatics o Thromboembolic disorders o Venous insufficiency o Varicose veins o Lymphatic disorders Esophagus and Diaphragm o Motility disorders o Gastroesophageal reflux disease o Barrett s esophagus o Perforation/Mallory-Weiss tear o Diverticulum o Esophageal cancer o Caustic injury o Varices o Diaphragmatic hernia o Diaphragmatic injury/rupture Stomach and Duodenum o Gastritis/gastropathy o Peptic ulcer/h. pylori o Volvulus o Diverticula o Menetrier s Disease o Bezoars o Postgastrectomy syndromes o Neoplasms: benign; malignant o Arteriovenous malformations; GAVE; watermelon stomach o Dieulafoy s lesion o Varices o Gastroparesis o Duodenal diverticulum o Crohn s disease o SMA syndrome Small Intestine o Crohn s disease o Celiac disease o Enteritis/enteropathy o Neoplasms: benign; polyps; malignant o Small intestinal fistulas o Diverticulum; Meckel s o Blind loop syndrome o Pneumatosis o Short bowel syndrome/intestinal failure o Intestinal obstruction o Motility disorders/ileus o Mesenteric ischemia Page 2.1.4

22 Learning Objectives (Mandatory) General Surgery Colon and Rectum o Mechanical obstruction o Paralytic ileus/pseudo-obstruction o Inflammatory bowel disease: Crohn s; ulcerative colitis o Ischemic colitis o Infectious colitis o Pseudomembranous colitis o Radiation enterocolitis o Diverticular disease o Megacolon o Volvulus: sigmoid; cecal o Polyps and polyposis syndromes o Neoplasms: benign; malignant; HNPCC o Solitary rectal ulcer o Rectal prolapse o Constipation/motility disorders/functional disorders o Pneumatosis o Angiodysplasia/vascular malformations o Colorectal bleeding o Foreign bodies of the rectum o Rectal trauma Anus o Neoplasms: benign; malignant o Anal infections/sexually-transmitted disease o Condyloma/AIN o Hemorrhoids o Fistula o Fissure o Pruritis ani o Incontinence o Levator ani syndrome Appendix o Appendicitis o Neoplasms: benign; malignant o Crohn s disease Liver and Portal System o Abscess o Cyst o Neoplasms: benign; malignant o Portal hypertension and its manifestations Biliary Tract/Gallbladder o Gallstone disease and its manifestations o Choledochal cyst o Sclerosing cholangitis o Cholangiohepatitis o Neoplasms: benign; malignant o Hemobilia Pancreas o Pancreatitis: acute; chronic o Cyst o Periampullary neoplasms: benign; malignant o Endocrine disorders of the pancreas Page 2.1.5

23 Learning Objectives (Mandatory) General Surgery Spleen o Operative indications for splenectomy o Hypersplenism o Neoplasms: benign; malignant o Metabolic disorders o Erythrocyte disorders o Autoimmune disorders o Vascular disorders o Cyst o Infections/abscess o Splenosis o Hematologic effects of splenectomy o Postsplenectomy sepsis Peritoneum and Retroperitoneum o Peritonitis o Abscess o Ascites o Adhesions o Retroperitoneal fibrosis o Retroperitoneal hematoma o Neoplasms/pseudomyxoma o Internal hernia Omentum and Mesentery o Omental torsion o Omental cyst o Mesenteric vascular disease o Neoplasms: benign; malignant Abdominal Wall/Hernia o Rectus sheath hematoma o Neoplasms: benign; malignant o Inguinal hernia o Femoral hernia o Umbilical hernia o Ventral hernia o Spigelian hernia o Lumbar hernia o Obturator hernia o Richter s hernia o Parastomal hernia Adrenal o Cushing s syndrome o Adrenogenital syndrome o Primary aldosteronism o Addison s disease o Estrogen-secreting neoplasms o Pheochromocytoma o Neuroblastoma o Ganglioneuroma o Cyst o Metastatic disease Other Clinical Problems o Gastrointestinal bleeding o Intestinal obstruction o The acute abdomen o Morbid obesity/bariatric surgery Page 2.1.6

24 Learning Objectives (Mandatory) General Surgery Perform a complete and appropriate assessment of a patient Elicit a history that is relevant, concise and accurate Perform a focused physical examination that is relevant and accurate Select medically appropriate investigations in a resource-effective and ethical manner Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans Use preventive and therapeutic interventions effectively Implement an effective management plan in collaboration with a patient and his/her family Demonstrate effective, appropriate and timely application of preventive and therapeutic interventions relevant to the practice of General Surgery Ensure appropriate informed consent is obtained for therapies Ensure patients receive appropriate end-of-life care The PGY-1 resident will be able to: Perform many of the above clinical skills Correctly diagnose the common general surgical problems Formulate management strategies; will often require corroboration or modification by more senior individual The junior resident will be able to: Perform the above clinical skills Complete the data gathering process Correctly diagnose most general surgical problems Formulate management strategies; will require corroboration or modification by more senior individual The senior/chief resident will be able to: Perform the above clinical skills Complete the data gathering process efficiently Correctly diagnose all general surgical problems Formulate management strategies completely, even for complex or difficult problems Demonstrate proficient and appropriate use of procedural skills Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the practice of General Surgery Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the practice of General Surgery Ensure appropriate informed consent is obtained for procedures Appropriately document and disseminate information related to procedures performed and their outcomes Ensure adequate follow-up is arranged for procedures performed Compile and maintain an accurate and complete electronic data base (T-Res log) of all operative procedures performed as a General Surgery resident Page 2.1.7

25 Learning Objectives (Mandatory) General Surgery Residents at all levels of training will be able to: Apply knowledge and expertise to performance of technical skills relevant to the practice of General Surgery Assist in the operating room Master the techniques of gentle tissue handling The PGY-1 resident will be able to: Initiate the process of technical skills development by assisting in simple procedures, under supervision Develop familiarity with surgical instruments and suture materials Position and drape patients for general surgical procedures Demonstrate the principles of gentle tissue handling The junior resident will be able to: Perform the above technical skills Perform some common general surgical procedures, under supervision The senior/chief resident will be able to: Perform the above technical skills Competently and independently perform most general surgical procedures Lead a team in the safe,effective and efficient operative management of patients Deal with operative circumstances that may be unusual or unexpected Supervise and teach more junior residents in performing operative procedures Having completed the rotation in General Surgery, the resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training) Operative Procedures PGY-1 Junior Senior/Chief General Diagnostic and Therapeutic Procedures Arterial puncture S S S Venipuncture/venous cutdown S S S Central venous catheter insertion S S S Insertion/removal of venous access reservoir (Portacath) S S S Endotracheal intubation S S S Insertion/removal of peritoneal dialysis catheter S S S Injection of varicose veins S S S Urinary catheter insertion S S S Nasogastric tube insertion S S S Tracheostomy A S S Cricothyrotomy A S S Needle/tube thoracostomy S S S Pericardiocentesis for trauma A S S Pericardiotomy for trauma A S S Paracentesis/diagnostic peritoneal lavage S S S Integumentary System Incision/drainage of subcutaneous abscess S S S Foreign body removal S S S Page 2.1.8

26 Learning Objectives (Mandatory) General Surgery Operative Procedures PGY-1 Junior Senior/Chief Excision of benign skin lesions S S S Wide excision of melanoma A S S Excision of subcutaneous lesions S S S Excision of pilonidal sinus disease S S S Excision of hidradenitis suppurativa A S S Suture of laceration S S S Creation of skin flaps A S S Split thickness skin grafts A S S Full thickness skin grafts A S S Breast Aspiration of breast mass/lesion S S S Core biopsy (True-cut) of breast mass S S S Incision/drainage of breast abscess S S S Excision of benign breast neoplasm S S S Partial mastectomy/lumpectomy A S S Total (simple) mastectomy A S S Modified radical mastectomy A A S Axillary dissection A A S Sentinel lymph node biopsy A A S Excision of mammary ducts (Adair) A S S Subcutaneous mastectomy A A S Head and Neck Excision of thyroglossal duct cyst (Sistrunk) A A S Excision of cystic hygroma A A S Excision of branchial cleft cyst/sinus A A S Excisional biopsy of cervical lymph node A S S Radical/modified radical neck dissection A A A/S Excision of parotid gland A A S Excision of submandibular gland A A S Thyroid lobectomy A A S Total thyroidectomy A A S V-excision of lip cancer A S S Vermilionectomy A S S Biopsy of premalignant/malignant oral cavity lesion A S S Hematologic/Lymphatic Biopsy of enlarged lymph nodes (cervical; axillary; inguinal; A S S scalene) Staging laparotomy for Hodgkin s disease A A S Ileoinguinal lymph node dissection A A S Open splenectomy A A/S S Laparoscopic splenectomy A A A/S Endoscopic Procedures Esophagogastroduodenoscopy NA S S Colonoscopy NA S S Flexible sigmoidoscopy NA S S Rigid sigmoidoscopy S S S Endoscopic biopsy techniques NA S S Endoscopic injection therapy NA S S Endoscopic variceal banding NA S S Hemorrhoid banding S S S Page 2.1.9

27 Learning Objectives (Mandatory) General Surgery Operative Procedures PGY-1 Junior Senior/Chief Endoscopic polypectomy NA S S Endoscopic thermal techniques NA S S Endoscopic detorsion of sigmoid volvulus NA S S Percutaneous endoscopic gastrostomy A A S Endoscopic dilation techniques NA S S Diagnostic laparoscopy A S S Choledochoscopy A A/S S Esophageal Procedures Laparoscopic esophagomyotomy (Heller myotomy) A A A/S Open transabdominal hiatus hernia repair/fundoplication A A A/S Laparoscopic transabdominal hiatus hernia A A A/S repair/fundoplication Repair of perforated esophagus A A S Repair of Mallory-Weiss tear A A S Esophagogastrectomy A A A/S Gastroduodenal Procedures Open wedge excision of gastric GIST/other lesions A A S Laparoscopic excision of gastric GIST/other lesions A A A/S Open partial gastric resection with Billroth I/Billroth II/Rouxen-y A A/S S reconstruction Laparoscopic partial gastric resection with Billroth I/Billroth A A A/S II/Roux-en-y reconstruction Open total gastrectomy A A S Open gastroenterotomy A S S Laparoscopic gastroenterotomy A A A/S Open surgical gastrostomy techniques (Stamm/Janeway) A A/S S Laparoscopic surgical gastrostomy techniques A A A/S Open pyloroplasty A A/S S Laparoscopic pyloroplasty A A A/S Open pyloromyotomy A A/S S Laparoscopic pyloromyotomy A A/S A/S Open gastrotomy and oversewing of bleeding gastric ulcer A A/S S Oversewing of bleeding duodenal ulcer A A/S S Vagotomy techniques A A A/S Open omental patch of perforated peptic ulcer A S S Laparoscopic omental patch of perforated peptic ulcer A A S Laparoscopic gastric bypass with Roux-en-y gastrojejunostomy for morbid obesity A A A Small Intestinal Procedures Open enterostomy (end/loop/feeding) A S S Laparoscopic enterostomy A A S Closure of enterostomy A A S Laparotomy and enterolysis for intestinal obstruction A A/S S Open small intestinal resection/anastomosis A S S Laparoscopic small intestinal resection/anastomosis A A A/S Open resection of Meckel s diverticulum A S S Laparoscopic resection of Meckel s diverticulum A A S Open enteroanastomosis A S S Laparoscopic enteroanastomosis A A A/S Stricturoplasty for Crohn s disease A A/S S Page

28 Learning Objectives (Mandatory) General Surgery Operative Procedures PGY-1 Junior Senior/Chief Colon and Rectal Procedures Open appendectomy A/S S S Laparoscopic appendectomy A S S Open colostomy (end/loop) A A/S S Laparoscopic colostomy A A A/S Colostomy closure A A/S S Open colonic resection/anastomosis (segmental/subtotal) A A/S S Sigmoid resection with Hartmann for perforated A A/S S diverticulitis Laparoscopic colonic resection (segmental/subtotal) A A/S S Open anterior resection with total mesorectal excision A A/S S (TME) Laparoscopic anterior resection with total mesorctal A A S excision (TME) Open abdominoperineal resection with total mesorectal A A/S S excision (including perineal portion of the procedure) Laparoscopic-assisted abdominoperineal resection with A A A/S total mesorectal excision (including perineal portion of the procedure) Total proctocolectomy with Brooke ileostomy for colitis A A S Pelvic pouch procedure with stapled j-pouch for ulcerative A A A/S colitis Pelvic pouch procedure with total colectomy/rectal A A A/S mucosectomy and stapled j-pouch/handsewn ileoanal anastomosis for FAP/dysplasia Open takedown of Hartmann A A/S S Laparoscopic takedown of Hartmann A A A/S Transanal excision of rectal polyp A S S Laparoscopic repair of rectal prolapse A A A/S Perineal rectosigmoidectomy for rectal prolapse A A/S S Anorectal Procedures Excision of thrombosed hemorrhoid S S S Hemorrhoidectomy A A/S S Hemorrhoid banding S S S Hemorrhoid injection S S S Stapled hemorrhoidopexy A A A/S Lateral internal sphincterotomy for anal fissure A A/S S Excision of anal fissure A A/S S Incision/drainage of perianal abscess S S S Incision/drainage of ischiorectal abscess S S S Anal fistulotomy techniques, including: A A/S S Probing of fistula tract Seton placement Mucosal advancement flap Fistula plug placement Anoplasty with v-y mucosal advancement flap A A/S S Anal dilatation S S S Anal sphincter repair A A A/S Excision/fulguration of condylomata acuminata A A/S S Excision and mapping for AIN/Bowen s disease A A/S S Repair of rectovaginal fistula with mucosal advancement flap A A S Page

29 Learning Objectives (Mandatory) General Surgery Operative Procedures PGY-1 Junior Senior/Chief Incision/drainage of pilonidal abscess S S S Excision of pilonidal sinus disease A S S Liver Procedures Open liver biopsy A S S Laparoscopic liver biopsy A A/S S Wedge excision of liver lesion A A/S S Left lateral segmentectomy A A/S S Left hepatic lobectomy A A A/S Right hepatic lobectomy A A A/S Left trisegmentectomy A A A/S Right hepatic lobectomy A A A/S Right trisegmentectomy A A A/S Open radiofrequency ablation of liver lesion A A A/S Open decompression/management of liver abscess/cyst A A/S S Laparoscopic decompression/management of liver abscess/cyst A A A/S Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and cholangiography A S S Open cholecystostomy A S S Laparoscopic cholecystostomy A S S Open common bile duct exploration A A S Laparoscopic common bile duct exploration A A A/S Biliary-intestinal anastomosis A A/S S Operative management of choledochal cyst or neoplasm A A/S S Pancreatic Procedures Drainage of pancreatic abscess A S A/S Pancreatic necrosectomy A A/S S Open drainage of pancreatic pseudocyst by anastomosis to A A/S S stomach or intestine Laparoscopic drainage of pancreatic pseudocyst by A A A/S anatomosis to stomach or intestine Puestow procedure A A A/S Local excision of pancreatic lesion A A/S S Distal pancreatectomy A A/S A/S Pancreaticoduodenectomy (Whipple procedure) A A A/S Hernia and Abdominal Wall Procedures Elective open repair of inguinal hernia using tension-free A S S mesh technique Elective laparoscopic repair of inguinal hernia A A/S S Emergency repair of incarcerated/strangulated inguinal A A/S S hernia using Cooper s ligament (McVay) technique Elective open repair of femoral hernia using tension-free A S S mesh technique Elective laparoscopic repair of femoral hernia A A/S S Emergency repair of incarcerated/strangulated femoral A A/S S hernia using Cooper s ligament (McVay) technique Open repair of ventral (incisional) hernia A S S Laparoscopic repair of ventral (incisional) hernia A A/S A/S Repair of parastomal hernia A A/S S Repair of lumbar hernia A A/S S Page