surgical critical care, bariatric surgery

Transcription

1 Rotation: Resident Level: Essential Content Areas/Expertise: St. Paul McClelland PGY1 Alimentary tract, hepatobiliary, skin, soft tissues, hernia, surgical critical care, bariatric surgery Goal: To develop residents who are able to identify, diagnose, and treat general surgical problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Skin and soft tissue infections Acute abdomen Morbidly obese patients undergoing bariatric surgery Hepatobiliary disorders, including cholecystitis, pancreatitis, and benign liver diseases Gastric and small bowel pathology, including upper gastrointestinal bleeding, peptic ulcer disease, small bowel obstruction, and appendicitis Hernias, including inguinal, umbilical, incisional, ventral Benign diseases of the colon and rectum Vascular access Perform and communicate a comprehensive history and physical examination of patients, including a 14 point review of systems Understand the importance of defining a complete, multidisciplinary treatment care plan prior to initiating operative management Wound Healing Identify appropriate versus inadequate wound healing Differentiate wound healing by primary closure, delayed primary closure, and healing by secondary intention Identify and Initiate management of dehiscence, evisceration, and extensive wound debridement Identify and differentiate wound complications: infection, hematoma, and seroma Recognize clinical parameters that predict impaired wound healing in surgical patients Fluids and Electrolytes Write perioperative intravenous fluid orders for patients following routine and complex operations taking into consideration operative factors, patient factors, and current metabolic status Understand the assessment of intravascular volume status in the postoperative patients and appropriate response to correct to a euvolemic state Perioperative Care Identify indications for operative and non operative treatment of common surgical problems Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk patient Assist and assume graduated responsibility in the comprehensive perioperative management of general surgery patients including one half day a week in the multidisciplinary surgery clinic

2 Recognize signs and symptoms of postoperative complications including but not limited to: Wound infection or seroma Anastomotic leak Postoperative hemorrhage Pulmonary embolism or deep vein thrombosis Bowel obstruction Bile leak or ductal injury Closed suction drainage malfunction Adynamic ileus Sepsis Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform suture placement and removal in the clinic, bedside, and operating room Participate in operations and procedures commensurate with level of experience as determined by the supervising surgical residents and general surgery faculty Obtain hemostasis Identify common surgical instruments, suture materials and their proper use Manage central venous catheters, urinary catheters, gastrostomy and jejunostomy tubes Insert, maintain, and remove operative tubes and drains Evaluate and explain management of complications in common surgical problems in surgical patients Establish and maintain sterile technique; practice isolation precaution when indicated Core Competency: Medical Knowledge Anatomy Identify anatomic landmarks of the: Head and neck Extremities including lymph nodal basins Inguinal region Abdomen and pelvis Recognize anatomic abnormalities on physical examination Diagnostic studies and laboratory Request appropriate consultations Order and interpret diagnostic studies in a cost effective manner Verify radiographically appropriate placement of central lines, endotracheal tubes, chest tubes, drains Identify indications, risks, benefits, and potential complications of radiographic and laboratory studies Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the

3 problems typically seen in general surgical patients Become familiar with radiographic studies including but not limited to: Chest xray and KUB CT scan of the abdomen Contrast studies of the gastrointestinal tract Identify the role of endoscopic intervention in the management of postoperative bariatric surgery complications and choledocholithiasis Pathophysiology Identify the pathophysiologic alterations present in morbidly obese patients Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some common general surgical problems Skin and soft tissue infection Small bowel obstruction Acute abdomen Appendicitis Biliary tract diseases, including cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis Diverticulitis Gastrointestinal bleeding Sepsis Pharmacology and pharmacokinetics Identify common drug interactions Develop an understanding of the mechanisms for commonly used vasoactive agents (dopamine, norepinephrine, vasopressin, dobutamine) Explain the indications for and understand the mechanism of common agents used for chemoprophylaxis of venous thromboembolism in postoperative general surgical patients. Explain the mechanism of action of antiplatelet and anticoagulation agents, including knowledge of appropriate cessation of therapy prior to elective surgical procedures. List appropriate antimicrobial therapy for: Empiric surgical site infection prophylaxis Empiric treatment of sepsis Methicillin resistant Staphylococcal infections Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the surgical patient census in a timely fashion

4 Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Gastrointestinal and Endocrine Surgery Demonstrate competent work ethic by consistently and dependably carrying out duties with honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our scheduled conferences including: Gastrointestinal/Endocrine Surgery Morbidity and Mortality Conference Multidisciplinary Discharge Rounds on 4West St. Paul Hospital Educational Conference Presentations Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents surgical oncology faculty Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding general surgery Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using:

5 SCORE Online UTSW reference textbooks Online literature review through OVID (Library website) Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the surgical team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing Rotation: Resident Level: Essential Content Areas/Expertise: St. Paul McClelland PGY2 Alimentary tract, hepatobiliary, skin, soft tissues, hernia, surgical critical care, bariatric surgery Goal: To develop residents who are able to identify, diagnose, and treat general surgical problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Skin and soft tissue infections Acute abdomen Morbidly obese patients undergoing bariatric surgery Hepatobiliary disorders, including cholecystitis, pancreatitis, and benign liver diseases Gastric and small bowel pathology, including upper gastrointestinal bleeding, peptic ulcer disease, small bowel obstruction, and appendicitis Hernias, including inguinal, umbilical, incisional, ventral Benign diseases of the colon and rectum Vascular access Assess and supervise PGY1 and intermediate surgical housestaff in the assessment and management of above conditions Model behaviors for PGY1 and intermediate surgical housestaff by assuming responsibility for the perioperative and outpatient management of assigned patients Ask for guidance effectively in unusual, confusing, or complex surgical problems or patients Perform and communicate a comprehensive history and physical examination of patients,

6 including a 14 point review of systems Understand the importance of defining a complete, multidisciplinary treatment care plan prior to initiating operative management Wound Healing Identify appropriate versus inadequate wound healing Differentiate wound healing by primary closure, delayed primary closure, and healing by secondary intention Identify and Initiate management of dehiscence, evisceration, and extensive wound debridement Identify and differentiate wound complications: infection, hematoma, and seroma Recognize clinical parameters that predict impaired wound healing in surgical patients Fluids and Electrolytes Write perioperative intravenous fluid orders for patients following routine and complex operations taking into consideration operative factors, patient factors, and current metabolic status Understand the assessment of intravascular volume status in the postoperative patients and appropriate response to correct to a euvolemic state Perioperative Care Identify indications for operative and non operative treatment of common surgical problems Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk patient Assist and assume graduated responsibility in the comprehensive perioperative management of general surgery patients including one half day a week in the multidisciplinary surgery clinic Recognize signs and symptoms of postoperative complications including but not limited to: Wound infection or seroma Anastomotic leak Postoperative hemorrhage Pulmonary embolism or deep vein thrombosis Bowel obstruction Bile leak or ductal injury Closed suction drainage malfunction Adynamic ileus Sepsis Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform suture placement and removal in the clinic, bedside, and operating room Participate in operations and procedures commensurate with level of experience as determined

7 by the supervising surgical residents and general surgery faculty, including but not limited to: Hernia repair (inguinal, umbilical) Cholecystectomy Appendectomy Placement of tunneled central venous lines Drainage of skin and soft tissue infections Obtain hemostasis Identify common surgical instruments, suture materials and their proper use Manage central venous catheters, urinary catheters, gastrostomy and jejunostomy tubes Insert, maintain, and remove operative tubes and drains Evaluate and explain management of complications in common surgical problems in surgical patients Establish and maintain sterile technique; practice isolation precaution when indicated Core Competency: Medical Knowledge Anatomy Identify anatomic landmarks of the: Head and neck Extremities including lymph nodal basins Inguinal region Abdomen and pelvis Recognize anatomic abnormalities on physical examination Diagnostic studies and laboratory Request appropriate consultations Order and interpret diagnostic studies in a cost effective manner Verify radiographically appropriate placement of central lines, endotracheal tubes, chest tubes, drains Identify indications, risks, benefits, and potential complications of radiographic and laboratory studies Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the problems typically seen in general surgical patients Become familiar with radiographic studies including but not limited to: Chest xray and KUB CT scan of the abdomen Contrast studies of the gastrointestinal tract Identify the role of endoscopic intervention in the management of postoperative bariatric surgery complications and choledocholithiasis Pathophysiology Identify the pathophysiologic alterations present in morbidly obese patients Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some common general surgical problems Skin and soft tissue infection Small bowel obstruction Acute abdomen Appendicitis Biliary tract diseases, including cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis

8 Diverticulitis Gastrointestinal bleeding Sepsis Pharmacology and pharmacokinetics Identify common drug interactions Understand the mechanisms for commonly used vasoactive agents (dopamine, norepinephrine, vasopressin, dobutamine) and factors important in selection Explain the indications for and understand the mechanism of common agents used for chemoprophylaxis of venous thromboembolism in postoperative general surgical patients. Explain the mechanism of action of antiplatelet and anticoagulation agents, including knowledge of appropriate cessation of therapy prior to elective surgical procedures. List appropriate antimicrobial therapy for: Empiric surgical site infection prophylaxis Empiric treatment of sepsis Methicillin resistant Staphylococcal infections Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the surgical patient census in a timely fashion Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Gastrointestinal and Endocrine Surgery Demonstrate competent work ethic by consistently and dependably carrying out duties with

9 honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our scheduled conferences including: Gastrointestinal/Endocrine Surgery Morbidity and Mortality Conference Multidisciplinary Discharge Rounds on 4West St. Paul Hospital Educational Conference Presentations Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents surgical oncology faculty Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding general surgery Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online literature review through OVID (Library website) Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the surgical team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing

10 Rotation: St. Paul McClelland Resident Level: Essential Content Areas/Expertise: PGY3 Alimentary tract, hepatobiliary, skin, soft tissues, hernia, surgical critical care, bariatric surgery Goal: To develop residents who are able to identify, diagnose, and treat general surgical problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Skin and soft tissue infections Acute abdomen Morbidly obese patients undergoing bariatric surgery Hepatobiliary disorders, including cholecystitis, pancreatitis, and benign liver diseases Gastric and small bowel pathology, including upper gastrointestinal bleeding, peptic ulcer disease, small bowel obstruction, and appendicitis Hernias, including inguinal, umbilical, incisional, ventral Benign diseases of the colon and rectum Vascular access Assess and supervise PGY1 and intermediate surgical housestaff in the assessment and management of above conditions Model behaviors for PGY1 and intermediate surgical housestaff by assuming responsibility for the perioperative and outpatient management of assigned patients Ask for guidance effectively in unusual, confusing, or complex surgical problems or patients Perform, provide direct supervision for, and communicate a comprehensive history and physical examination of patients, including a 14 point review of systems Participate and lead discussion for the development of a complete, multidisciplinary treatment care plan prior to initiating operative management Identify patients at risk for complications following major and minor procedures and take measures to minimize the risk of adverse events as well as monitor early signs of adverse events Formulate differential diagnosis for common surgical problems Provide meaningful consultations and communicate these plans to requesting treatment teams in a respectful, comprehensive, timely fashion with the assistance of supervising surgical faculty Write perioperative intravenous fluid orders for patients following routine and complex operations taking into consideration operative factors, patient factors, and current metabolic status Understand the assessment of intravascular volume status in the postoperative patients and appropriate response to correct to a euvolemic state Perioperative Care Identify indications for operative and non operative treatment of common general surgical problems Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk

11 patient Assist and assume graduated responsibility in the comprehensive perioperative management of surgical patients including one half day a week in the multidisciplinary surgery clinic Recognize signs and symptoms of postoperative complications including but not limited to: Wound infection or seroma Anastomotic leak (gastric bypass, bowel resections) Postoperative hemorrhage Bowel obstruction Pulmonary embolism or deep vein thrombosis Bile leak or ductal injury Closed suction drainage malfunction Adynamic ileus Sepsis Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform suture placement and removal in the clinic, bedside, and operating room Participate as primary surgeon in operations and procedures commensurate with level of experience as determined by the supervising general surgery faculty including but not limited to: Hernia repair (inguinal, umbilical, incisional, ventral) Laparoscopic and open cholecystectomy Appendectomy Small bowel and colon resections Arteriovenous fistulas Laparoscopic gastric band and sleeve gastrectomy Describe technical steps and necessary decisions and options during operative procedures Evaluate and explain management of complications in common surgical problems in general surgical patients Core Competency: Medical Knowledge Anatomy Identify anatomic landmarks of the: Head and neck Extremities Inguinal region Abdomen and pelvis Recognize anatomic abnormalities on physical examination Diagnostic studies and laboratory Request appropriate consultations Order and interpret diagnostic studies in a cost effective manner

12 Verify radiographically appropriate placement of central lines, endotracheal tubes, chest tubes, drains Identify indications, risks, benefits, and potential complications of radiographic and laboratory studies Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the problems typically seen in general surgical Become familiar with radiographic studies including but not limited to: Abdominal ultrasound Chest, abdominal, and extremity CT scan/mri Upper gastrointestinal contrast studies Pathophysiology Identify the pathophysiologic alterations present in morbidly obese patients, and apply this knowledge in the treatment of postoperative patients. Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some common general surgical problems: Skin and soft tissue infection Small bowel obstruction Acute abdomen Appendicitis Biliary tract diseases, including cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis Diverticulitis Gastrointestinal bleeding Sepsis Pharmacology and pharmacokinetics Understanding of the mechanisms for commonly used vasoactive agents (dopamine, norepinephrine, vasopressin, dobutamine) and demonstrate appropriate selection based on patients clinical condition Explain the indications for and understand the mechanism of common agents used for chemoprophylaxis of venous thromboembolism in postoperative general surgical patients Explain the mechanism of action of antiplatelet and anticoagulation agents, including knowledge of appropriate cessation of therapy prior to elective surgical procedures List appropriate antimicrobial therapy for: Empiric surgical site infection prophylaxis Empiric treatment of sepsis Methicillin resistant Staphylococcal infections Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online literature review through OVID on Library website

13 Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the surgical team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the surgical patient census in a timely fashion Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Gastrointestinal and Endocrine Surgery Demonstrate competent work ethic by consistently and dependably carrying out duties with honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our conferences including:

14 Gastrointestinal/Endocrine Surgery Morbidity and Mortality Conference Multidisciplinary Discharge Rounds on 4West St. Paul Hospital Educational Conference Presentations Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents surgical faculty Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding general surgery Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Independently access, appraise and apply information from relevant texts and evidence based literature including SCORE to care of the patient Rotation: St. Paul McClelland Resident Level: Essential Content Areas/Expertise: PGY5 Alimentary tract, hepatobiliary, skin, soft tissues, hernia, surgical critical care, bariatric surgery Goal: To develop residents who are able to identify, diagnose, and treat general surgical problems and deliver this care in a compassionate, efficient, contemporary, evidence based manner. Residents will work as members of an interdisciplinary team both in conferences and during active clinical care. Core Competency: Patient care Assessment and Management Describe perioperative management of: Skin and soft tissue infections Acute abdomen Morbidly obese patients undergoing bariatric surgery Hepatobiliary disorders, including cholecystitis, pancreatitis, and benign liver diseases Gastric and small bowel pathology, including upper gastrointestinal bleeding, peptic ulcer disease, small bowel obstruction, and appendicitis Hernias, including inguinal, umbilical, incisional, ventral Benign diseases of the colon and rectum Vascular access Assess and supervise PGY1 and intermediate surgical housestaff in the assessment and

15 management of above conditions Model behaviors for PGY1 and intermediate surgical housestaff by assuming responsibility for the perioperative and outpatient management of assigned patients Ask for guidance effectively in unusual, confusing, or complex surgical problems or patients Perform, provide direct supervision for, and communicate a comprehensive history and physical examination of patients, including a 14 point review of systems Participate and lead discussion for the development of a complete treatment care plan prior to initiating operative management Identify patients at risk for complications following major and minor procedures and take measures to minimize the risk of adverse events as well as monitor early signs of adverse events Formulate differential diagnosis for common surgical problems Provide meaningful consultations and communicate these plans to requesting treatment teams in a respectful, comprehensive, timely fashion with the assistance of supervising surgical faculty Wound Healing Identify appropriate versus inadequate wound healing Assist PGY1 and intermediate residents, and medical students in wound management Differentiate wound healing by primary closure, delayed primary closure, and healing by secondary intention and treat accordingly Identify and Initiate management of dehiscence, evisceration, and extensive wound debridement Identify and differentiate wound complications: infection, hematoma, and seroma Recognize clinical parameters that predict impaired wound healing in surgical patients and take measures to optimize wound healing in those patients at greatest risk Critical Care and Perioperative care Apply basic tenets for surgical care in the design and implementation of a management plan for optimal patient care in the perioperative and outpatient setting Provide comprehensive care for all patients in the ICU and standard postoperative setting Describe the anatomy, pathophysiology, and management for disease encountered in the general surgical patients including but not limited to: Skin and soft tissue infections Acute abdomen Complications of bariatric surgery (leak, stricture, gastrogastric fistula) Hepatobiliary disorders, including cholecystitis, pancreatitis, and benign liver diseases Gastric and small bowel pathology, including upper gastrointestinal bleeding, peptic ulcer disease, small bowel obstruction, and appendicitis Hernias, including inguinal, umbilical, incisional, ventral Benign diseases of the colon and rectum Mesenteric ischemia in the critically ill Actively incorporate basic science principles into patient care plans Assess, document, and manage perioperative risk factors for diseases and conditions Identify indications for operative and non operative treatment of common surgical problems Calculate and monitor nutritional goals Understand the role of total parenteral nutrition in the malnourished or nutritionally at risk patient Assist and assume graduated responsibility in the comprehensive perioperative management of surgical patients including one half day a week in the multidisciplinary surgery clinic

16 Recognize signs and symptoms of postoperative complications including but not limited to: Wound infection or seroma Anastomotic leak (gastric bypass, bowel resections) Postoperative hemorrhage Bowel obstruction Pulmonary embolism or deep vein thrombosis Bile leak or ductal injury Closed suction drainage malfunction Adynamic ileus Sepsis Evaluate and manage postoperative complications promptly and communicate assessment to the supervising surgical team member in a timely fashion Provide timely and accurate documentation of all assessments, plans, interventions, and transfers of care Participate in high fidelity patient review for handoffs and sign outs with necessary team members Surgical and Technical Skills Perform handwashing before and after every patient encounter Comply with all patient safety initiatives and report concerns to supervising surgical faculty Describe rationale and technique of minimizing tissue injury during surgical procedures Perform as primary surgeon with graduated responsibility during common and complex surgical procedures including but not limited to: Hernia repair (inguinal, umbilical, incisional, ventral) Laparoscopic and open cholecystectomy Common bile duct exploration Appendectomy Gastric, small bowel, and colon resections Arteriovenous fistulas Laparoscopic gastric band, bypass, and sleeve gastrectomy Describe technical steps and necessary decisions and options during operative procedures Evaluate and explain management of complications in common surgical problems in general surgery patients Establish and maintain sterile technique; practice isolation precaution when indicated Core Competency: Medical Knowledge Anatomy Understand the complex multidimensional topographic and functional anatomy of the following structures particularly as they relate to common procedures: Skin and soft tissues of the extremities, trunk, and head and neck including nodal basins Abdominal organs, particularly the stomach, liver, pancreas, biliary tree, colon, rectum, and retroperitoneum including layered three dimensional neurovascular anatomy Recognize anatomic abnormalities on physical examination and radiographic studies Teach other learners on the team about critical anatomic landmarks and the importance of anatomic familiarity during resection Diagnostic studies and laboratory Request and provide appropriate consultations Order and interpret diagnostic studies in a cost effective manner. Appropriately discuss the

17 indications and results with radiological, endoscopic, and surgical faculty, housestaff, patients, and families for: Interventional radiology procedures including drainage procedures of the biliary tree CT Scan of the head, neck, chest, abdomen, and extremities MRI EUS/ERCP Upper gastrointestinal contrast studies Develop an initial understanding of normal and abnormal radiologic anatomy as it relates to the problems typically seen in general surgery patients Identify the role of endoscopic intervention in the management of benign biliary strictures, choledocholithiasis, upper gastrointestinal bleeding, and bariatric surgery complications. Interpret the following findings based on imaging studies Presence of appendicitis, small bowel obstruction, cholecystitis Adequate gastric band placement Anastomotic leak and deep tissue infection Pathophysiology Identify the pathophysiologic alterations present in morbidly obese patients, and apply this knowledge in the management of postoperative bariatric patients. Explain some of the fundamental pathophysiologic derangements critical to the development and treatment of some common general surgical problems: Skin and soft tissue infection Small bowel obstruction Acute abdomen Appendicitis Biliary tract diseases, including cholelithiasis, cholecystitis, choledocholithiasis, pancreatitis Diverticulitis Gastrointestinal bleeding Sepsis Pharmacology and pharmacokinetics Understanding of the mechanisms for commonly used vasoactive agents (dopamine, norepinephrine, vasopressin, dobutamine) and demonstrate appropriate selection based on patients clinical history and condition Explain the indications for and understand the mechanism of common agents used for chemoprophylaxis of venous thromboembolism in postoperative general surgical patients Explain the mechanism of action of antiplatelet and anticoagulation agents, including knowledge of appropriate cessation of therapy prior to elective surgical procedures Oversee TPN orders with the assistance of the Nutrition team, manage TPN complications, and make decisions regarding the initiation and cessation of TPN Adjust for influence of hepatic and renal insufficiency in the administration, dosing, and selection of perioperative medications Culture/ethnicity Recognize and respect of healthcare practices, communication customs, and beliefs of ethnic and cultural groups Identify commonalities in people s medical conditions that transcend culture and ethnicity Identify biases and barriers between the healthcare community and cultural/ethnic groups

18 Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online literature review on OVID via the Library website Core Competency: Systems based practice Identify barriers to accessing health care for patients across cultural, economic, racial backgrounds Participate in discussion and development of a cost effective patient management plan that analyzes risks and benefits Collaborate with institutional resources, such as social services, home health, etc., for effective discharge planning Acquire specific information about rehabilitation services, indications for referral and potential benefits Identify system issues that may contribute to medical mortality and communicate these to the general surgery team Follow up with reference physician post operative/discharge about patient s care Access and transfer patient s medical records when appropriate Apply appropriate documentation for coding and billing Core Competency: Interpersonal and Communication Skills Document a comprehensive history, examination, assessment, and plan for assigned surgical patients Document timely daily progress notes that describe clinically important issues or changes in patient care plans Write routine orders (admission, preoperative, postoperative) and communicate urgent or emergent orders to the nursing staff Document and revise essential patient care information on the general surgery patient census in a timely fashion Present patient information on rounds and at transitions of care with emphasis on patient safety Present assessment and plan for all assigned patients on daily faculty rounds Apply information from daily faculty rounds into patient care including medical chart information Discuss medical errors or professional mistakes honestly and openly within the context of quality improvement to promote patient safety, trust, and self learning Communicate effectively with patients, family, nursing staff, residents, physician assistants, fellows, and faculty, and the public across socioeconomic and cultural backgrounds Patient and Family Communication/Education Provide accurate, straightforward information to patients and families in a compassionate and understandable manner Use informed consent properly Listen with cultural, ethnic, gender, racial, and religious sensitivity Core Competency: Professionalism Act as resident leader of the entire General Surgery resident team in terms of teaching effort, ethics, and modeled behavior Adhere to all ACGME work hour policies as set forth by the Department of Surgery and supported by the Division of Gastrointestinal and Endocrine Surgery Demonstrate competent work ethic by consistently and dependably carrying out duties with

19 honesty, integrity, self motivation, and self discipline Use available resources when ethical, medical, or professional problems arise Strive to provide excellence in the delivery of surgical care and patient safety including participation in Quality Improvement projects such as regular participation in our scheduled Surgical Oncology multidisciplinary conferences including: Gastrointestinal/Endocrine Surgery Morbidity and Mortality Conference Multidisciplinary Discharge Rounds on 4West St. Paul Hospital Educational Conference Presentations Prepare in advance for faculty rounds, operative cases, and outpatient clinic Accurately report duty hours on a daily basis and prospectively identify and communicate potential work hour issues to the supervising residents surgical faculty Participate in regular Department of Surgery educational conferences and activities Adhere to institutional code of conduct, demeanor, behavior, and attire Recognize capabilities and limitations of self, team, and institution Respect all individuals Care for patients compassionately by consistently demonstrating respect for patient privacy, dignity, and autonomy Log cases and duty hours and complete evaluations in a timely fashion Core Competency: Practice based learning and improvement Read assigned readings and identify materials for self study regarding general surgery Guide residents and other learners on the team in the selection of reading materials and the use of medical literature to cultivate an example of effective lifetime learning Use independent self study and assessment programs Identify common sources of medical errors, and explain steps to avoid or minimize them Self reflect about adverse events and near misses to improve patient safety and care Participate in education of medical students and other learners Explain how to recognize and manage postoperative complications Incorporate formative and summative feedback from team members and rotation faculty to identify areas of weakness and improve overall performance Independently access, appraise and apply information from relevant texts and evidence based literature to care of the patient using: SCORE Online UTSW reference textbooks Online literature review (Library website)