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GENERAL SURGERY CLERKSHIP 2009–10
Course Director
Joseph Sorrento, MD
Northport VAMC
Northport, NY 11768
631-754-7918
JJSORRENTO@aol.com
Course Objective
The goal of the clerkship is to provide students with an extensive experience in the evaluation and treatment of patients with surgical disease. Specifically, we emphasize:
1. The evaluation and initial management of acute abdominal pain
2. The evaluation and initial management of the traumatized patient
3. The preoperative and postoperative management of surgical patients
4. The evaluation and initial management of certain malignancies (especially, breast cancer, colon cancer, pancreatic cancer, gastric cancer, melanoma)
5. The evaluation and initial management of certain vascular and cardiovascular conditions (especially, carotid artery disease, abdominal aortic aneurysm, ischemic heart disease [from a surgical perspective], distal vascular disease)
6. The evaluation and initial management of abdominal wall hernias
7. Wound healing
8. The evaluation and initial management of surgical causes of jaundice
9. The ethical care of surgical patients
We also provide exposure to subspecialty surgery and the office practice of surgery in part as practiced by attending physicians and in the ambulatory setting.
Toward these ends, the clerkship stresses:
1. Direct student participation in the care of patients from initial presentation, through treatment and on a daily basis until discharge
2. Student acceptance of personal responsibility as a physician for the care of the patient, acting always under the supervision of the attending and resident surgical team (the student will act and function as an integral member of the surgical team; the student is, therefore, expected to be versed in the knowledge applicable to the care of the patient, being particularly prepared to address issues of differential diagnosis, treatment alternatives and operative interventions; daily rounds and chart notations are expected)
3. The student is also expected to attend relevant seminars and grand rounds as part of his/her clinical team (in addition to his/her ward responsibilities, the student will prepare for and attend scheduled didactic sessions; these sessions will involve lectures, student case presentations and problem-based learning (PBL) modules. Performance on these modules will be factored into the calculation of the clinical grade. In this way, the student is expected to master the fund of knowledge relevant to surgery and develop the required skills of evaluation and diagnosis exemplified in surgical care.
Course Description
It is not the purpose of the surgical clerkship to train medical students in the practice of surgery. The third-year clerkship in surgery is designed to provide the student with a broad experience in the general surgical disciplines. This experience is designed to emphasize direct patient contact, including all phases of evaluation, diagnosis and treatment. Students spend a period of time on a general surgical service (4 weeks at University Hospital and the VAMC, and 6 weeks at Winthrop–University Hospital). During this portion of the clerkship, they are given the opportunity to follow patients from initial presentation and evaluation, participate in the patient’s surgical therapy, and care for the patient in the postoperative recovery period until discharge from the hospital. Opportunity is also provided to participate in surgical office practice (at University Hospital and Winthrop–University Hospital) or in outpatient clinics (at the VAMC), allowing greater participation in both the pre hospital evaluation of elective patients and the long term follow-up of patients seen in-hospital.
The remainder of the surgical clerkship is split among associated surgical services, providing the student with a broad experience in the surgical disciplines. Emphasis continues on the evaluation and diagnosis of surgical disease. Additional experience is provided in the disciplines of vascular and cardiothoracic surgery, urology, orthopaedic surgery and otolaryngology.
While patient care responsibilities are foremost, didactic teaching sessions are held each week throughout the rotation. These sessions utilize group presentations, lecture, and problem-based learning formats. During these sessions, the student is expected to master and demonstrate the fund of knowledge necessary for the general practice of medicine as it relates to surgical disease. Performance on problem sessions, presentations, and ward responsibilities form the basis of the clinical grade. In addition, the student will meet regularly with a faculty preceptor. Finally, evaluations will include a written (in-house) exam, a written board examination, and oral examination.
Clinical Responsibilities
Each student is assigned to a surgical team of residents and attending physicians. The student is expected to function as a member of the surgical team under the supervision of residents and attending physicians. The student will participate in the initial evaluation of patients, including the performance of an admitting history and physical (H&P) examination. It is the responsibility of the student to review the H&P with his/her resident or attending physician. The student will follow patients on a daily basis, presenting those patients on morning rounds and writing appropriate chart notes. Admission, daily and postoperative orders may be written by the student under the direction of a physician. He/she may perform basic tests and procedures under the direct supervision of a physician until he/she is credentialed to perform such tasks independently. The student will prepare for and attend surgical procedures performed upon those patients that he/she is following. In addition, the student may be assigned to attend ambulatory care clinics, operations upon patients not otherwise assigned or duties attendant to the performance of the responsibilities of the surgical team to which he/she is assigned. Additional experience or opportunities, particularly in surgical subspecialties may be arranged on an ad hoc basis as desired by the student through consultation with the clerkship site director.
It is expected that the student will attend the clinical activities of his/her assigned service on a daily basis. If a student is unable to attend the activities of clinical service for personal reasons, the student will notify his/her chief surgical resident and the site director. The site director must be notified for an absence to be excused. Unexcused absence from clinical activities may be the basis of a failing clinical grade.
Students will be on-call every fourth night and can go home at 2 PM or at the end of the last lecture of the day, whichever is later.
Preceptors
Students will be assigned to a preceptor group of approximately four students. The preceptor will be an attending surgeon engaged in active practice. It is expected that the student will meet with his/her preceptor weekly. The substance of these meetings will include:
1. Right upper quadrant abdominal pain
2. Right lower quadrant abdominal pain
3. Left upper quadrant abdominal pain
4. Left lower quadrant abdominal pain
5. Jaundice
6. Bowel obstruction
7. Fluid & electrolytes
8. Nutrition
Documentation
Students are expected to maintain a log of all patient evaluations and operations attended. It is expected that each student will perform a complete history and physical examination and follow the patient through his/her complete clinical course for a minimum of 20 patients during the 8-week surgical rotation. In addition, the students will maintain a log of their nights on-call. These logs will be presented at the time of the oral examination and may provide the basis of oral examination questions.
General Orientation Information
All students beginning surgical clerkships, regardless of clinical site, report to the Health Sciences Center, Stony Brook, T-19, O25, Department of Surgery classroom at 8:45 AM sharp on the first day of the clerkship. This is a 1-day orientation prior to the official start of the individual hospital clerkships. This orientation includes a review of the course guidelines and requirements. An opportunity to ask questions and raise special concerns will be given. Brief seminars on wound closure, knot tying, and conduct in the operating room will be held. Students will be directed to report the next morning to their respective surgical clerkship sites for the start of the rotation. Information regarding call facilities, parking, meals, start times and other issues specific to the clinical site will be provided at the clerkship hospital. Additionally, PBL manuals will be distributed. Course objective books are to be purchased at the bookstore on Level 2. This later material lists the objectives and skills that should be mastered by the conclusion of the clerkship and are the primary source for oral exam questions and many of the written exam questions.
Basic Course Schedule
The surgical clerkship consists of an eight week rotation. During the orientation to Surgery, each student will be assigned to a preceptor group and receive a copy of the syllabus. Policies of grading, attendance and call will be presented. Written and oral examinations will be given at the end of the full 8-week rotation.
Grading
Clerkship grades will be assigned as Honors, High Pass, Pass, Fail, and Incomplete. In addition to the final grade, a narrative describing the student’s performance will be forwarded to the office of the Dean of Academic Affairs. All grades and comments are entered into Conet by the Department of Surgery. Grades are calculated as follows:
n Clinical Grade 50%
n Written Exam (SHELF EXAM) 12.5%
n Written Exam (IN-HOUSE EXAM) 12.5%
n Oral Exam 25%
The clinical grade will be assigned based upon the following evaluations:
n Preceptor evaluation
n Faculty evaluations
n Chief Resident evaluations
n PBL module evaluations
At the conclusion of the general surgery clerkship, the student will sit for an oral examination. This examination will emphasize clinical problem solving skills and differential diagnosis. The examination will be conducted utilizing standardized questions. In general, the topics for the exam include questions on the following topics: 1) trauma/critical care medicine; 2) surgical oncology; and 3) benign general surgery. Scores of the examiners will be averaged and become the final Oral Exam Grade.
At the conclusion of the surgical clerkship, the student will be required to write a standardized National Board examination. This examination will emphasize mastery of the general fund of knowledge relating to the practice of surgery. Grading of the examination will be done by standardized national curve. Final clerkship grades are calculated as described above.
At the conclusion of the surgical clerkship, the student will be required to write an in-house exam which emphasizes a greater depth of knowledge than is examined by a multiple choice test. Most of the questions will be uncued questions taken from a previously validated (at another medical school) bank of questions. This examination will emphasize mastery of the type of knowledge which would be specifically taught during this clerkship.
The following standards are applied:
Honors
n Clinical grade 
B+ and Written exams 95%ile and Oral Exam A–
or
n Clinical grade A– and Written exams 85%ile and Oral Exam A–
or
n Clinical grade A+ and Written exams 80%ile and Oral Exam A
or
n Clinical grade A+ and Written exams 85%ile and Oral Exam B+
High Pass
n Clinical grade A– and Written exams 75%ile and Oral Exam A–
n Clinical grade B+ and Written exams 85%ile and Oral Exam A–
n Clinical grade A– and Written exams 85%ile and Oral Exam B
Pass
n Clinical grade C– and Oral Exam D and Written (SHELF) exam grade 15%ile or Average of SHELF and IN-HOUSE EXAM 20%ile
Fail
n Clinical grade < C– or Written (SHELF) exam grade < 15%ile and Average of SHELF and IN-HOUSE EXAM < 20%ile
Recommended Texts
So that the student may have a clearer insight about what a student should be learning during the surgical clerkship, the student should purchase, after the beginning of the clerkship, The Manual of Surgical Objective, 4th edition, prepared by the Curriculum Committee of the Association for Surgical Education (details on how to obtain this is given during orientation).
In order to master the requisite fund of knowledge relating to surgery and achieve a passing grade on the written examination, it is necessary to read an adequate textbook. Review books, pocket manuals, syllabi, and books of "surgical secrets" may be valuable aids to your understanding but are not adequate to master the knowledge necessary to successfully pass this course. The following list is provided for your guidance. It is not to be considered exhaustive or an endorsement of any particular text.
n Brunicardi FC, editor. Schwartz's Principles of Surgery [see e-books @ HSC Library]. 8th ed. New York: McGraw Hill.
n Davis JH, editor. Clinical Surgery. St Louis: CV Mosby.
n Doherty GM, Way LW, editors. Current Surgical Diagnosis and Treatment [see e-books @ HSC Library]. 12th ed. New York: Lange Medical Publications/McGraw-Hill.
n Greenfield LJ, editor. Surgery: Scientific Principles and Practice. 3rd ed. Philadelphia: Lippincott Williams & Wilkins.
n Townsend CM Jr, editor. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice [see e-books @ HSC Library]. 18th ed. Philadelphia: Elsevier Saunders.
Additional Information
Statement Regarding AIDS and Seropositive Patients
It is the philosophy of the directors of the surgical clerkship that patients with AIDS are to be cared for in accordance with their desires and without compromise of medical and ethical principles. However, students rotating on a surgical service are at increased risk of infection relating to needle-stick or other injuries during the conduct of an operation due to their lack of experience at the operating table. For this reason, students are excused and actively discouraged from participating in operations involving AIDS patients or patients known to be seropositive for HIV or hepatitis. The student may observe these operations and is otherwise expected to participate in care as he/she would for any other patient.
Statement Regarding Winthrop–University Hospital
All medical students beginning a rotation at Winthrop–University Hospital must call the Employee Health Office prior to their start date:
Ms. Barbara Richardson
Employee Health Office
222 Station Plaza North
Mineola, NY 11501
516-663-2534
