Residency Training in General Surgery

OBJECTIVES FOR OUTPATIENT CLINICS

I. Overall objectives that apply to all residents in all outpatient clinics:

OUTPATIENT CARE

Includes Office Experience/Pre- and Post-Hospital Care of the Surgical Patient

GOALS:

● Maintain continuity in terms of care of the patient with surgical diseases from pre-hospital evaluation through post-surgical management and follow-up.

● Develop and hone skills in history taking, physical examination, interpersonal communication, critical appraisal, and self-directed learning.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1.             Delineate the components of and discuss the importance of a focused history and physical examination performed in an outpatient setting on a patient with a surgical disease.

2.             Identify indications for, technical aspects of, and typical results from the following screening tests:

                a.             Stool guaiac

                b.             Sigmoidoscopy

                c.             Prostate screening

                d.             Mammography

3.             Demonstrate a working knowledge of the natural history of surgical diseases:

                a.             If untreated

                b.             If treated surgically

                c.             If treated non-surgically

4.             Distinguish between different types of biopsy techniques in an outpatient setting.

5.             Specify indications for such common office procedures as:

                a.             Core-needle biopsy/fine-needle aspiration

                b.             Incision and drainage of abscesses (recognize those requiring in-hospital operating room drainage)

                c.             Sigmoidoscopy/anoscopy

                d.             Excision of cutaneous lesions

6.             Delineate hospital mechanisms for admitting patients.

7.             Estimate costs of hospitalization and various surgeries.

8.             Describe the expected appearance of wound sites at various postoperative intervals.

9.             Delineate appropriate pain medications and dosages.

10.          Specify the need for drains and tubes, stating the types and special requirements for replacement or removal.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

1.             Demonstrate the ability to obtain the essential elements of a focused preoperative history, including assessment of medications.

2.             Perform a complete physical examination, paying special attention to assessment of cardiopulmonary risk of surgery.

3.             Order appropriate and cost-effective laboratory tests for screening and pre- and post-operative evaluation.

4.             Accurately interpret clinical laboratory results, pathology reports, and radiographic studies.

5.             Synthesize historical findings, physical examination, and laboratory data for diagnosis.

6.             Develop appropriate plans for management.

7.             Order appropriate consultations.

8.             Appropriately and sensitively counsel the patient and patient's family regarding:

                a.             Disease entity (prognosis, treatment options, additional treatment)

                b.             Surgical issues

                                (1)           Operative risks (possible complications, including mortality)

                                (2)           Operative procedures (preparation, testing, duration of surgery and hospitalization)

                                (3)           Anesthesia

                                (4)           Prognosis (curative vs. palliative)

                c.             Other treatment options (no treatment [explain natural history of disease] and non-surgical therapy)

                d.             Informed consent

                e.             Community resources

9.             Perform appropriate office procedures.

10.          Arrange patient admission to hospital facility.

11.          Explain the prospective surgical approach to the patient.

12.          Postoperatively, obtain appropriate follow-up history, including:

                a.             General well-being

                b.             Pain control

                c.             Presence of fever

                d.             Nutritional state (ability to eat, nausea)

                e.             Bowel function

                f.              Level of activity

                g.             Compliance with instructions (medications, complications of medication, physical therapy)

13.          Perform appropriate postoperative examination of the surgical site.

14.          Provide appropriate wound care. Identify and manage wound problems, including:

                a.             Superficial wound separation; abdominal dehiscence

                b.             Vascular surgery incisions and wounds (diabetic foot problems and their impact)

                c.             Seromas

                d.             Infections (cellulitis or abscess, determining the need for antibiotics, drainage, office vs. operating room care)

                e.             Lymphoceles

                f.              Incisional hernia

                g.             Foreign body reaction (to sutures, staples)

15.          Ascertain the need for further consultative support, and arrange for patient referral when indicated.

16.          Assess the need for further follow-up, including:

                a.             Arrangement for home nursing evaluation and care

                b.             Assessment/arrangement for other support (e.g., the homemaker)

                c.             Prescribing appropriate dietary supplements

                d.             Hospice care

17.          Prescribe appropriate pain medication.

18.          Assess patient's ability to maintain level of activity (drive motor vehicle, work, exercise, sexual activity)

19.          Appropriately and sensitively communicate with patient and family.

20.          Appropriately communicate with referring physicians in a timely fashion regarding patient outcome.

21.          Develop the ability to teach in office settings (for nurses, patients, medical students, and junior house officers).

COMPETENCY-BASED ATTITUDINAL OBJECTIVES:

1.             Have a working understanding of the role of the surgeon as primary care giver in office and clinical settings.

2.             Demonstrate professionalism, empathy, and compassion by showing respect for a patient's privacy and self-esteem during aspects of the physical examination which may be uncomfortable, frightening, or embarrassing for the patient.

3.             Demonstrate an awareness of, and respect for, patient autonomy, especially regarding:

                a.             Decisions about therapy

                b.             Decisions not to treat

                c.             Issues of patient compliance

4.             Show an awareness of, and respect for, the contributions of other office staff members (nurses, technicians, secretaries).

5.             Demonstrate a respect for medical students in office and/or clinic settings.

6.             Recognize patient or patient family responsibilities that may affect the timing of surgery.

7.             Demonstrate an understanding of, and sensitivity to, patient socioeconomic concerns regarding such issues as:

                a.             Insurance and the ability to pay for physician services, hospitalization, and prescribed medications

                b.             Possible loss of work time and wages

8.             Demonstrate sensitivity and appropriate flexibility regarding patient fears and concerns, including:

                a.             Preoperatively

                                (1)           Anxiety about pain and procedure's findings

                                (2)           Embarrassment

                b.             Intraoperatively

                                (1)           Pain and individual response to pain

                                (2)           Modesty

                                (3)           Comfort

                c.             Postoperatively

                                (1)           Ability to care for self                          

                                (2)           Drugs                                                    

                        (3)        Level of function

                        (4)        Prognosis

9.             Display a working knowledge of the management of the office and the outpatient surgical setting.

II. Objectives of all resident attended outpatient clinics at each participating institution:

STONY BROOK UNIVERSITY MEDICAL CENTER

BURN CLINIC. The resident learns to evaluate the success of previous burn treatment as well as the possibility for the need of additional care. To evaluate the progress of patients involved in rehabilitation programs.

CARDIAC SURGERY CLINIC. The resident is to understand the preoperative work-up and diagnosis of the cardiac patient. To understand the complications of chest surgery.

GENERAL SURGERY. The resident is to evaluate the wide variety of patients seen by a general surgeon and be able to diagnose and prepare a treatment plan. To evaluate the postoperative patient.

PEDIATRIC SURGERY CLINIC. The resident learns to identify and diagnose pediatric surgical illnesses as well as preoperative work-up as well as postoperative follow-up. To develop professional skills in dealing with parents and pediatric patients.

SURGICAL ONCOLOGY. The resident is to learn to evaluate the oncology patient and the work-up needed for the patient to reach the operating room, diagnose and treat solid tumors, and be able to formulate a treatment plan in the postoperative oncology patient.

TRAUMA CLINIC. The resident learns to coordinate patient care between numerous services to provide optimal care to the trauma patient. To evaluate the success of previous treatment and the progress of patients in rehabilitation programs.

VASCULAR CLINIC. It is expected that the resident be able to diagnose vascular disease states and understand the diagnostic work-up needed for the preoperative vascular patient, as well as non operative management of vascular disease. To make informed decisions about vascular diagnostic and therapeutic interventions based on patient information. To evaluate postoperative outcomes and plan further treatment plans.

NORTHPORT VA MEDICAL CENTER

All clinics at the Northport VA Medical Center are resident run clinics and all patients at these clinics are seen by residents under faculty supervision. This is the optimum environment for continuity of care. The resident is expected to see the patient pre operatively, diagnose, initiate the work-up and follow the patient to the operating room. The resident cares for the patient postoperatively and see his/her patient in the clinic for postoperative follow-up. In addition, the resident is expected to schedule the patient for surgery.

GENERAL SURGERY CLINIC. The Resident is expected to diagnose, treat and arrange an appropriate work-up for the general surgery patient. The resident is expected to understand and be able to treat the complications for each procedure performed. To arrange for appropriate follow-up.

HEAD AND NECK CLINIC. The assigned residents are responsible for performing initial evaluation of all new patients and participate in the management of all follow-up patients. In addition to evaluating patients, the assigned resident is responsible for preparing and presenting cases at tumor board. The residents are also expected to become proficient in diagnostic endoscopy.

PLASTIC SURGERY CLINIC. Under faculty supervision, the resident is expected to be proficient in the diagnosis and treatment of skin cancers. To do initial patient assessment and follow-up of postoperative patients. The residents perform minor plastic procedures as well as punch biopsies. The residents schedule cases and perform preoperative diagnostic work-up.

PROCTOLOGY CLINIC. The residents are expected to perform initial evaluation of patients. They are to become proficient in hemorrhoidal banding, rigid and flexible sigmoidoscopy as well as mannometry. That they understand anal disease and treatment modalities. Faculty is present as in all clinics.

THORACIC SURGERY CLINIC. Residents perform the preoperative work-up and follow-up of thoracic surgery patients. They are expected to understand diseases of the chest and their treatment. To understand operative and nonoperative treatments of chest disease.

VASCULAR CLINIC. The same objectives are expected as in the general surgery clinic. In addition, the vascular resident is to arrange appropriate vascular studies in the vascular lab, interpret and understand the implications. In addition, to understanding Peripheral Vascular Disease he/she must be able to diagnose and treat venous disease.

WINTHROP–UNIVERSITY HOSPITAL

GENERAL SURGERY CLINIC/VASCULAR SURGERY CLINIC. Under a variety of attending physicians, the resident are to understand the workings of a private practice office. To insure that pre- and post-operative management is ensured.