Surgical Associate Manual 07 08

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Department of Surgery

Surgical Associate Manual

2007-2008


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Table of Contents

Topic Page

Mission Statement 4

Introduction 4

Faculty 5 - 6

Residents 7 8

Administrative Chief Resident 8

Educational Program 9

Graduated Levels of Responsibility 9 - 11(Supervision)

Block Diagram of Rotations 12 - 13

Summary of Goals and Objectives 14 - 37of Rotations

Shands Research Laboratory 38

ACGME Core Competencies 39 - 40

Educational Methods and 41 - 42Assessment Table

ACS Code of Professional Conduct 43

Conferences 44 - 47Departmental ConferencesResident CoursesService Conferences

Visiting Professors

Textbooks and Reading 48

In-Training Examination 48

Awards 48 - 49


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Topic Page Topic Page

Duty Hour and other Policies 50

Duty Hours Recording 50 - 51

Evaluation 51ResidentFacultyProgram

Grievance Policy/ 52 - 55Academic Discipline Policy

Fringe Benefits 55 - 58

Impaired Physician 58

Vacation/Leave Requests 58 - 60

Mentor Program 60

Outside Employment 61

Sexual Harassment 62

Supervision 62 - 63

Technical Standards 64

ACGME 65

American Board of Surgery 65 - 68

American College of Surgeons 68

Case Lists 68-69

Code of Conduct 69

Conscious Sedation 69

Dress Code 70

Meal tickets 71

Medical records 71-72

Medical Students 72

Prescription Writing 73

Resident Teaching 74

Social Events 74-75

Residency Office 75-76

Also available on website @ http://www.surgery.ufl.edu/Residency/Current/news.aspx

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EDUCATIONAL MISSION STATEMENT

The fundamental mission of the Department of Surgery at the University of Florida is to provideexcellence in patient care, research and education. The purpose of the training program in generalsurgery is to offer a supportive, learner-centered educational environment that maximizes the potential

of each surgical resident to become independent practitioners capable of providing the highest qualitysurgical care. The department is dedicated to this educational mission that also encourages educationalinnovation and continuous programmatic improvement.

INTRODUCTION

The goal of the surgical residency program is to prepare the resident to function as a qualifiedpractitioner of surgery at the high level of performance expected of a board-certified specialist. Theeducation of surgeons for the practice of general surgery encompasses education in basic sciences,training in cognitive and technical skills, development of clinical knowledge, and maturity in the

acquisition of surgical judgment. The educational program uses a variety of educational methods tofacilitate learning of the fundamentals of basic science as applied to clinical surgery, including: theelements of wound healing, homeostasis, hematologic disorders, oncology, shock, circulatoryphysiology, surgical microbiology, respiratory physiology, gastrointestinal physiology, genitourinaryphysiology, surgical endocrinology, surgical nutrition, fluid and electrolyte balance, metabolic responseto injury including burns, musculoskeletal biomechanics and physiology, immunobiology andtransplantation, applied surgical anatomy, and surgical pathology.

Professional attitudes highly valued by this program include complete dedication to patient care, theability to make sound ethical and scientific judgments in the care of patients, a scholarly mind set anddedication to life long learning, the ability to work well with others and to become part of a team, andthe capacity for hard work with a positive attitude. The residents in this program are expected to teachand share knowledge with colleagues, students and other health care providers. Critical thinking basedon a thorough reading of the available literature and respect for the cultural, religious, and individualpreferences of the patient and family will be the basis for decisions made that affect the lives of patients.The well-trained surgeon must be aware of the cost and societal implications of decisions and be able toadapt to the evolving health care system in this country. Individuals completing the surgery residencywill have the skills to be leaders and valued members of the medical community in whichever settingthat individual wishes to practice.

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FACULTY

Armstrong John H MD Trauma Ast Professor University of Virginia

Beaver Thomas M MD Thoracic Assistant Professor Univ of Wisconsin

Behrns Kevin E MD Gen/ GI Professor, Prog. Director Mayo Medical School

Beierle Elizabeth A MD Pediatric Assistant Professor Univ of North Dakota

Berceli Scott A MD PhD Vascular Assistant Professor Univ of PittsburghBen-David Kfir MD General/GI Assistant Professor University of Florida

Bleiweis Mark S MD Thoracic Associate Professor Univ of California, San Diego

Cance William G MD Oncology Professor & Chairman Duke University Sch Med

Carter Chris MD VA-SICU Assistant Professor Oregon Health Sciences Univ

Cendan Juan C MD Woodward Assistant Professor Univ of Florida

Chen Mike K MD Pediatric Assistant Professor Univ of Texas, Hlth Sci Cente

Copeland Edward M MD Oncology Distinguished Professor Cornell University

Feranec Jessica MD Gynecology Assistant Professor University of Florida

Flynn Timothy C MD Vascular Professor & Aso Dean Baylor University

Fujita Shiro MD PhD Transplant Assistant Professor Faculty of Med Kyoto Univ

Grobmyer Stephen R MD Oncology Assistant Professor UT Southwestern

Hemming Alan W MD Transplant Associate Professor Univ of British Columbia, Can

Hess Philip J MD Thoracic Assistant Professor East Carolina University

Hochwald Steven N MD Oncology Assistant Professor New York University

Hollenbeck John I MD Trauma Adj Clinical Professor Ohio State University

Howard Richard J MD PhD Transplant Professor, Yale University

Huber Thomas S MD PhD Vascular Associate Professor University of Michigan

Islam Saleem MD, MPH Ped Surgery Assistant Professor AGA Khan University

Kayler Liise MD Transplant Assistant Professor AGA Khan University

Kays David W MD Pediatric Associate Professor Northwestern University

Kim Robin D MD Transplant Assistant Professor Jefferson Medical CollegeKlodell Charles T MD Thoracic Assistant Professor Univ of Louisville

Lee W Anthony MD Vascular Assistant Professor John Hopkins Sch of Med

Lottenberg Lawrence MD Trauma Clin Aso Professor Univ of Miami

Martin Tomas D MD Thoracic Associate Professor University of Texas

Martin Larry MD Acute Care Assistant Professor University of Florida

McDonald Anthony MD VA General Clinical Assoc Professor University of Florida

Moldawer Lyle L PhD Lab Professor University of Gothenberg

Mozingo David W MD Burn Professor University of Virginia

Nelson Peter R MD Vascular Assistant Professor Univ of Massachusetts

Ozaki Charles K MD Vascular Associate Professor Duke University

Reed Alan I MD Transplant Associate Professor Cornell University

Richards Winston T MD Burn Clinical Ast Professor Pennsylvania State University

Rout William R MD General/ GI Associate Professor University of Louisville

Sadove Richard C MD Plastic Clinical Associate Prof Rush Medical College

Sarosi George A MD Woodward Associate Professor Harvard Medical School

Scott Walter W MD Thoracic Clinical Ast Professor University of Virginia

Seagle Michael B MD Plastic Associate Professor Vanderbilt University

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Seeger James M MD Vascular Professor & Chief Medical Sch of Georgia

Staples Edward D MD Thoracic Associate Professor University of South Florida

Steele Matt MD Plastic Assistant Professor University of Florida

Stevens Amy MD VA Gen Chief, GYN Surgery Sect. University of Florida

Stinson Wade MD Thoracic Clinical Associate Prof. University of Kansas Med Sch

Taj-Eldin Samer MD VA-SICU Clinical Associate Prof University of FloridaTan Sanda A MD General/GI Assistant Professor Emory University Sch of Med

Tribble Curtis G MD Thoracic Professor Vanderbilt University

Zingerelli William MD VA Gen Associate Professor University of Florida

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RESIDENTS2007-2008

BASIC SURGERY RESIDENTS I (18) GENERAL SURGERY RESIDENTS IV (7)Abdul, Firas (Prelim) Caban, Angel M.

Alt, Jeremiah (pre-Anesthesia) Osian, Omeni N.Barbick, Michael (OMF) Rhodes, Stancie C.Clayton, Jessica R. (Prelim) Salcedo, Edgardo (Skeeter) S.Gutwein, Luke G. Walters, Hugh A.Hong, Michael S. Wilson, Jason P.Hughes, Matthew R. Winfield, Robert D. (Lab)Mann, Wesley (pre-Radiology)Miggins, Makesha V. (Prelim) GENERAL SURGERY RESIDENTS V (4)Moran, Colleen M. Anderson, Scott A.Nale, John C. (OMF) Delano, Matthew J. (Lab)Neichoy, Bo T. Hunt, Darrell L. (Lab)Ngatia, Josephat G. (Prelim) Velopulos, Catherine G.

Shemesh, Sivan (Prelim)Toskich, Beau B. (Prelim) GENERAL SURGERY RESIDENTS VII (1)Whiting, Bryant M. (pre-Urology) Garces, Christopher A.Willis, Daniel L. (pre-Urology)Yannaras, Steven (pre-Anesthesia) GENERAL SURGERY RESIDENTS VIII (1)

McAuliffe, Priscilla F.

BASIC SURGERY RESIDENTS II (8)Alderson, Nathan (Prelim)Campos, Sarah (Prelim)Cuenca, Alex G.Hutchens, Andrea E. (Prelim)Lee, Constance W. L.

Rossidis, GeorgiosWaterman, Alyson L.Yamaguchi, Dean J.

GENERAL SURGERY RESIDENTS III (6)Kim, Tad (Lab)Kissane, Nicole A.McDonald, J. BradyMortellaro, Vincent E.Stasik, Chad N.Warner, Elizabeth A. (Lab)

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PLASTIC SURGERY (3) VASCULAR SURGERY (2)Clayman, Mark (PGY V) Feezor, Robert J. (PGY IX)

Lee, Wayne (PGY VIII) Martin, Daniel (PGY VI)

Lentz, Ashley (PGY VI)

ORTHOPEDIC SURGERY (4)THORACIC SURGERY (4) Altbuch, Tristan (PGY I)Beauford, Robert (PGY VIII) Bruggeman, Adam (PGY I)

Ellman, Peter I. (PGY VII) Kinney, Nicholas (PGY I)

Mirzakhani, Pezhman (PGY VII) Stevens, Christopher (PGY 1)

Shofnos, Jason (PGY VII)

OTOLARYNGOLOGY SURGERY (3)NEUROSURGERY (2) Cox, Katherine (PGY I)Cox, Joseph (Bridger) (PGY I) Joseph, Debbie (PGY I)Sporrer, Justin (PGY I) Thomas, Rob (PGY I)

TRANSPLANT SURGERY (1)Zendejas, Ivan (PGY VII)

PEDIATRIC SURGERY (1)Paddock, Heather (PGY X)

Administrative Chief ResidentChris Garces, MD

The responsibilities of the administrative chief resident include oversight of the general surgery call schedule

(including vacation schedules), resident liaison to the Executive Education Committee, along with other chiefresidents provides assistance with monitoring of duty hours, and other administrative duties as assigned.

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EDUCATIONAL PROGRAM

Graduated Levels of Responsibility

Graduate medical education is based on the principle of progressively increasing levels of responsibility,

in caring for patients, under the supervision of the faculty. The faculty is responsible for evaluating theprogress of each resident in acquiring the skills necessary for the resident to progress to the next level oftraining. Factors considered in this evaluation include the residents clinical experience, judgment,professionalism, cognitive knowledge, and technical skills. These levels are defined as postgraduateyears (PGY) and refer to the clinical years of training that the resident is pursuing. The requirement fortraining in General Surgery is five years of clinical rotations. At each level of training, there is a set ofcompetencies that the resident is expected to master. As these are learned, greater independence isgranted the resident in the routine care of the patient at the discretion of the faculty who, at all times,remain responsible for all aspects of the care of the patient. As a general outline, the PGY I year isdevoted to learning the skills necessary to take care of patients on the floor and clinic and includesintensive care unit skills (VA Intensive Care Rotation). In the PGY II year, the resident has increasing

clinical responsibilities and operative experience. The VA night float and Trauma rotation provide thePGY II the opportunity to function as a surgical consultant with chief resident and faculty supervision.The PGY III year is a year where the resident is the middle manager on the general surgery services andexpands the basic surgical skills. The PGY IV and V years are chief years and when the young surgeonassimilates the clinical and operative skills necessary to practice the specialty. Additionally, the chiefsare expected to assume leadership roles in the administrative and educational objectives of theresidency. General responsibilities for each level follow below.

PGY I - Individuals in the PGY I year are closely supervised by senior level residents and faculty.Examples of tasks that are expected of PGY I physicians include: perform a history and physical exam,start intravenous lines, draw blood, order medication and diagnostic tests, collect and analyze test resultsand communicate those to the other members of the team and faculty, obtain informed consent, placeurinary catheters and nasogastric tubes, assist in the operating room and perform other invasiveprocedures under the supervision of the faculty or senior residents at the discretion of the responsiblefaculty member. The resident is expected to exhibit dedication to the principles of professionalpreparation in surgery (see below American College of Surgeon Professional Code) that emphasizes thepatient as the focus for surgical intervention. The first year resident must develop and implement a planof study, reading and research of selected topics that promotes personal and professional growth and beable to demonstrate successful use of the literature in dealing with patients. The resident should be ableto communicate with patients and families about the disease process and the plan of care as outlined bythe attending. At all levels, the resident is expected to demonstrate an understanding of thesocioeconomic, cultural, and managerial factors inherent in providing cost effective care.

PGY II - Individuals in the second post graduate year are expected to perform independently the dutieslearned in the first year and may supervise the routine activities of the first year residents. The PGY IImay perform some procedures without direct supervision such as insertion of central lines, arterial lines,diagnostic peritoneal lavage, proctosigmoidoscopy, chest tube insertion or placement of PA catheters.Second year residents may manage critically ill patients including initial trauma care, ventilatormanagement, resuscitation from shock, and anti-arrhythmic therapy. Residents at this level can performsurgical procedures under the direct supervision of faculty or senior level residents designated as

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teaching assistants. The PGY II should be able to demonstrate continued sophistication in theacquisition of knowledge and skills in the practice of surgery and further ability to functionindependently in evaluating patient problems and developing a plan for patient care. The resident at thesecond year level may respond to consults and learn the elements of an appropriate response toconsultation in conjunction with the faculty member. The resident should take a leadership role in

teaching the PGY I, and medical students, the practical aspects of patient care and be able to explaincomplex diagnostic and therapeutic procedures to the patient and family. The resident should be adeptat the interpersonal skills needed to handle difficult situations. The PGY II should be able to incorporateethical concepts into patient care and to discuss these with the patient, family and other members of thehealth care team.

PGY III -In the third year, the resident should be competent in the medical management of patientswith virtually any routine or complicated surgical condition and of supervising the PGY I and PGY II intheir daily activities. The resident is responsible for coordinating the care of multiple patients on thesurgical team assigned. Individuals in the third postgraduate year may perform all routine diagnosticand therapeutic procedures including endoscopy with direct supervision. The PGY III can perform

progressively more complex surgical procedures under the direct supervision of the faculty. It isexpected that the third year resident be adept in the use of the literature and routinely demonstrate theability to search selected topics and present these to the surgical team. At the completion of the thirdyear, the resident should be ready to assume senior level responsibility as the chief resident on selectedservices.

PGY IV - Individuals in the fourth postgraduate year assume an increased level of responsibility as thesenior resident on selected services and can perform the full range of complex surgical proceduresexpected of a general surgeon under the supervision of the faculty. The fourth year is one of seniorleadership and the resident should be able to assume responsibility for organizing the service andsupervising junior residents, interns and students. The resident should have mastery of the informationcontained in standard texts and be facile in using the literature to solve specific problems. The residentwill be responsible for presentations at conferences and for teaching junior residents and students on aroutine basis. The PGY IV should begin to have an understanding of the role of the surgeon in anintegrated health care delivery system and to be aware of the issues in health care management facingpatients and physicians.

PGY V - The fifth year surgical resident, under the supervision of the faculty, takes responsibility forthe management of the major general surgical teaching services. Throughout the chief year, residentscan perform most complex and high-risk procedures expected of a general surgeon with the approval ofthe attending surgeon. During the final year of training the resident should have the opportunity todemonstrate the mature ethical, judgmental and clinical skills needed for independent practice of generalsurgery. The PGY V gives formal presentations at scientific assemblies and assumes a leadership role inteaching on the surgical service. The mores and values of the profession should be highly developedincluding the expected selfless dedication to patient care, a habit of lifelong study and commitment tocontinuous improvement of self and the practice of surgery.

ALL YEARS - Residents at every level are expected to treat all other members of the health care teamwith respect and with a recognition of the value of the contribution of others involved in the care ofpatients and their families. The highest level of professionalism is expected at all times. Racial, ethnic

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or cultural slurs are never acceptable. Treat all others with the respect and consideration you wouldexpect for yourself. Ego and personality conflicts are not conducive to good patient care. Long hoursand the stress of surgical practice can precipitate conflict. The resident should be aware of the situationswhere this is likely to happen and try to compensate by not escalating the situation.

Each resident is expected to develop a personal program of reading. Besides the general reading in thespecialty of surgery, residents should seek directed reading daily with regard to problems that theyencounter in patient care or in the operating room. The resident is responsible for reading prior toperforming or assisting in cases that the resident has not yet had the opportunity to see. Residents areexpected to attend all conferences at the service and program level. The conference program is designedto provide a didactic forum to augment the residents reading and clinical experience.

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BLOCK DIAGRAM OF ROTATIONS

PGY I

The PGY I residents will complete 13 rotations, each of 4 weeks duration. The possible rotations are

listed below:

General Surgery/GIShands

Thoracic Surgery Shands

Trauma / ER Shands

Pediatric Surgery Shands

Surgical Oncology Shands

Vascular Surgery Shands

Burns Shands

Transplant Shands

Night Float - Shands Otolaryngology Shands

Urology Shands

I.C.U. Gainesville V.A.

General Surgery Gainesville V. A.

Plastic Surgery Gainesville V. A.

Thoracic Surgery Gainesville V. A.

Vascular Surgery Gainesville V. A.

Ambulatory Surgery

Lake City V.A.

PGY II

The PGY II residents rotate 6 weeks on each of the following services (unless otherwise specified):

PediatricSurgery

Shands

VascularSurgery

Shands

Night Float Gainesville

V.A.

Critical Care Shands

Trauma Shands

Burns Shands

SurgicalOncology -

Shands

PGY III

The PGY III residents rotate 10 weeks on each of the following services (unless otherwise specified):

General/GI Surgery Shands

CommunitySurgery - WPB

PediatricSurgery Shands at

AGH

General Surgery Gainesville V. A.

Thoracic Surgery Gainesville V. A.

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PGY IV

The PGY IV/Senior Residents rotate for three months on each of the following services (unlessotherwise specified):

Pediatric SurgeryShands Trauma Shands Vascular SurgeryGainesville V. A. Surgical OncologyShands

PGY V

The PGY V/Chief Residents rotate for three months on each of the following services (unless otherwisespecified):

Surgical OncologyShands

General/GI Surgery -Shands

Hepatobiliary Shands

General SurgeryGainesville V. A.

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GOALS AND OBJECTIVES OF ROTATIONS

Each service has a number of faculty members, usually 2-5, with whom the resident will work. There isan attending designated as chief of each service who is ultimately responsible for assigning the duties ofthe residents rotating on that service and defining the educational activities of the service. In addition, it

is the responsibility of the faculty to shape the educational experience of the residents on the rotationand to provide day-to-day guidance and feedback depending on the opportunities that present. Whatfollows is a general description of the various services and expected competencies of residents assignedto these services. This is in no way a complete listing but should give each resident a general idea ofexpectations for each experience. A more comprehensive listing can be found in Surgical ResidentCurriculum published by the Association of Program Directors in Surgery, a copy of which is in theprogram directors office.

University of Florida SHANDS HOSPITAL

Surgical Oncology - The faculty members of this general surgery service have a special interest andexpertise in the management of cancer. The service, in addition to general surgery, sees patients withmalignant diseases of the head and neck, breast, colon, rectum, as well as melanoma, sarcoma, and livertumors. There is a large outpatient experience giving the resident the opportunity to gain proficiency inthe diagnosis, preparation and long term follow up of the patient with neoplastic disease. Throughconferences and daily teaching rounds, the residents should learn the comprehensive, multidisciplinarymanagement of the cancer patient. There are 5 attendings and residents rotate at the PGY 1, PGY 2,PGY 4 and PGY 5 level. There are also two physician extenders with extensive experience in themanagement of these patients. The operative volume on this service permits the presence of both a PGY4 and PGY 5 who function as co-chief residents, but do not compete for operative cases.Responsibilities and general learning objectives include:

PGY I The PGY 1 responsible for the daily management of patients on the wards including gatheringdata, caring for wounds, and writing orders. The PGY I is expected to participate in clinics and theoperating room as well. At the end of the rotation the resident should be able to:

Perform a directed history and physical for patients with a wide variety of cancer diagnoses and beable to manage these patients in the hospital including the provision of appropriate nutritionalsupport.

Formulate an appropriate differential cancer diagnosis, and record an independent, written diagnosisfor each cancer patient assigned.

Design an appropriate nutritional support program for a cancer patient both pre- and post-

operatively. Discuss current theories of carcinogenesis including the genetic factors, immune factors and

environmental exposures that can lead to the development of malignancy.

Explain the prognosis, incidence and trends in common solid tumors.

Manage colostomies and ileostomies.

Perform minor procedures under the supervision of the faculty and senior residents.

Discuss the economic and psychosocial impact of a cancer diagnosis and the role of social servicesand community resources in the total management of the patient.

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PGY 2 Resident

To competently assess patients by taking an accurate history, performing a physicalexamination and obtaining necessary laboratory and imaging data. The PGY 2 residentshould focus on the care of the patients with breast and endocrine diseases.

To integrate clinical presentation and data to develop a treatment plan for all patients withemphasis on patients with breast and endocrine diseases.

To gather, read and interpret the medical literature necessary to manage patients withoncologic surgical conditions, especially breast and endocrine.

To effectively communicate to other health care providers and students the clinical findingsand pertinent data from the literature regarding patient treatment. This information should beshared at multidisciplinary breast and GI tumor conferences and the weekly DivisionalConference.

To participate in the operative care of patients and develop requisite motor skills tocompetently complete surgical procedures with focus on breast and endocrine operations.

To participate in weekly Divisional conference with emphasis on surgical outcome and

benchmarking versus NSQIP. To prepare and participate in the weekly Surgery 201.

To demonstrate exemplary professional conduct in interactions with patients, staff andfaculty while running the service.

To participate in the creation and refinement of perioperative orders sets for patients withoncologic diseases.

PGY 4 - The PGY 4 functions as a co-chief resident and is expected to gain considerable experience inthe operating room. At the completion of the rotation the resident should be able to:

Outline the diagnosis and management of common oncologic problems and general surgicalproblems usually encountered by general surgeons including the management of complications andnutritional needs.

Understand emerging theories of oncogenesis and their application to surgical care.

Explain in detail surgical options and procedures for the management of all types of head and neck,breast malignancies, colon and rectal tumors, melanoma, primary and metastatic liver tumors andsarcomas.

Stage specific neoplasms and relate stage to survival.

Be familiar with current adjuvant chemotherapy protocols.

Perform complex operative procedures under the supervision of the faculty.

Respond to consults for oncology surgery problems.

PGY 5 - This resident in the final stage of training is responsible for supervising the junior residents andstudents. The resident assumes responsibility for management of all patients on the service withsupervision by the faculty. The resident coordinates operating schedules and participates in complexprocedures in the operating room. At the completion of the rotation the resident should be able to:

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Independently manage patients with cancer including diagnosis, preoperative preparation andoperative care.

Assume teaching and scheduling responsibilities for the junior residents and students.

Counsel patients and families about procedures, prognosis, options and resources available to copewith the cancer diagnosis.

Interact professionally with other disciplines that treat the cancer patient and understand the role ofsurgery in the total care of the patient with a wide variety of cancer problems.

Critically assess new research findings as they apply to direct care of the patient.

Recognize and manage all complications of procedures done for cure or palliation.

General Surgery GI This Surgical Service is composed of three faculty members and a PGY 5, PGY3 and PGY 1. The faculty have a special interest in basic and advanced minimally invasive surgery,surgery for morbid obesity, endocrine surgery, pancreatic and biliary surgery, and colorectal disease.There is also a mid-level provider with extensive experience in the management of these patients.Responsibilities and general learning objectives include:

PGY 1 - Performs history and physical, coordinates pre and post operative care with the chief residentand attendings, sees patients in the outpatient setting and assists in surgery, performing tasks undersupervision. Upon completion of the rotation the resident should be able to:

Perform a complete history and physical in a timely and efficient manner.

Define the anatomy and physiology of the alimentary tract as it applies to common surgical diseases.

Outline the essential characteristics of routine diagnostic evaluation of the alimentary tract.

Effectively manage the routine care of patients undergoing abdominal surgery including themanagement of tubes, drains, ostomies and common complications.

Explain surgical and medical management of common gastrointestinal abnormalities such as pepticulcer disease, gallstones, upper and lower GI hemorrhage, diverticulitis, pancreatitis.

Perform less complex procedures such as the placement of lines under supervision and assisting inthe operating room.

Recognize the indications and surgical options for the use of minimally invasive techniques insurgical practice.

Understand the indications and recognize complications associated with operations for morbidobesity.

Explain the rational use of antibiotics in surgical practice.

Describe the anatomy and physiology of the thyroid, parathyroid and adrenals.

Understand the current management and surgical options for the management of inflammatorybowel disease.

PGY 3 The PGY 3 is the middle level manager who assists and guides the PGY I in the managementof the floor patients and has primary responsibility for the intensive care unit patients, consults,emergency room and conference preparation. The PGY 3 is expected to gain considerable experience inthe operating room. At the completion of the rotation the resident should be able to:

Understand the technology for basic laparoscopic surgery and the principles of advancedlaparoscopic surgery, and be able to perform the basic laparoscopic surgical procedures

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Comprehensively explain the anatomy, embryology, physiology, and pathophysiology of the liver,biliary tree, GI tract, pancreas, and spleen.

Manage all aspects of inpatient care both on the floor and in the Critical Care Unit for the patients onthe service under the direction of the chief resident and attending.

Evaluate consults and outpatient referrals and formulate a plan of action to present to the attending.

Act as surgeon under the direction of the attending in laparoscopic procedures and some complexprimary and secondary abdominal procedures.

Discuss the economic and psychosocial issues associated with malignant and life altering chronicdiseases and be able to use the resources in the institution to manage these patients in acompassionate and cost effective manner.

Gain proficiency in the operative skills associated with the care of patients with routine surgicalillnesses, especially those of the gallbladder and of hernia repairs.

PGY 5 The chief resident assumes responsibility for all activities on the service both clinically andeducationally under the direction of the attendings. This includes planning conferences, coordinatingthe operative schedule, interacting with referring physicians and rounding independently and with the

attending staff. At the completion of this rotation the resident should be able to:

Assume responsibility for the entire range of general surgery patients encountered in the practice ofthe specialty.

Demonstrate mastery of all aspects of care for patients with routine and complex uppergastrointestinal, hepatic, biliary and pancreatic disorders.

Manage a varied and busy inpatient and outpatient service by appropriate use of junior levelresidents and other resources in an efficient and cost-effective manner.

Perform all operative cases usually encountered by general surgeons in the upper gastro-intestinaltract, biliary system, pancreas and liver including laparoscopic procedures and operations forobesity.

Understand issues relating to quality assurance, risk management, cost containment and evolvingpractice systems.

Use the literature to practice evidence based medicine and present selected topics to other membersof the department at Grand Rounds, Morbidity and Mortality Conference, etc.

Comprehensively manage the trauma patient.

Be familiar with newer techniques in minimally invasive surgery, their indications and limitations.

Manage urgent and emergent problems that present in a tertiary hospital setting including trauma.

Be familiar with the ethical, socioeconomic, medical/legal, and cost containment issues of currentpractice.

Trauma Surgery - Surgery residents from most levels will rotate on the Trauma Service. Residents arean integral part of the care from the Emergency Department to the ICU, to the operating room to thefloor and then finally post-discharge in the outpatient clinic. The residents are part of themultidisciplinary team that has sit-down rounds twice weekly and walk round on a daily basis.Numerous opportunities are provided for resident presentation, work-up, management and didacticteaching opportunities exist on the service in three (3) trauma/emergency surgery/burn conferences andjournal club. At the completion of the rotation the resident should:

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Demonstrate complete understanding of the initial management of the injured patient includingresuscitation, fluid management, airway management and all aspects of surgical critical care.

Demonstrate the ability to evaluate, manage and operate on the emergency surgical patient including theacute abdomen and all aspects of soft tissue infection.

Competency-Based Knowledge Objectives:1) Understand the triage process for acutely injured patients.2) Define the criteria for a trauma alert3) Understand the role of pre-hospital management.4) Discuss the initial stabilization and management of the acutely injured patient in the trauma

resuscitation room.5) Recognize hemorrhagic shock and outline a plan for its management.6) Explain fluid and electrolyte management in the trauma resuscitation room, in the intensive care

unit and on the floor.7) Describe the pathophysiology of the acutely injured patient.

8) Differentiate between the management of blunt and penetrating trauma.9) Describe the management of traumatic brain injury.10) Understand the principles in the management of chest, abdominal and extremity trauma.11) Describe the management of spinal cord injury.12) Become competent in the principles of Advanced Trauma Life Support and be certified in ATLS

by the PGY1 level.13) Describe the pathophysiology of abdominal compartment syndrome.14) Demonstrate competency in ventilator management, nutritional assessment and management,

infection surveillance and antibiotic management.15) Create a management tree for the evaluation of the patient with acute abdominal pain and

conclude with a diagnosis and treatment plan.16) Recognize serious soft tissue infections, the urgency to operative intervention and the subsequent

management thereafter.17) Describe the indications and understand the management of the open abdomen.18) Learn the principles of injury prevention including driving under the influence of alcohol or

drugs, helmet use, and seatbelt use.19) Understand the role of physical therapy, rehabilitation medicine and family and social services in

the management of all patients on the ACS service.

Performance-Based Knowledge Objectives:1) Management of the airway of trauma patients including rapid sequence intubation and surgical

airways and percutaneous tracheostomy.2) Access the trauma patient for arterial blood.3) Place tube thoracostomy.4) Insert large bore intravenous introducers in subclavian, femoral and saphenous veins.5) Access the femoral artery for catheter monitoring.6) Perform Focused Abdominal Sonography for Trauma and complete a certified training course.7) Perform diagnostic peritoneal lavage.8) Understand the principles and perform urgent ED thoracotomy.9) Become proficient in recognizing traumatic injuries on plain radiographs and CT scans.

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10) Learn and perform appropriate prepping and draping of trauma patients in the operating room.11) Participate and perform any and all operative procedures on trauma and emergency surgery

patients with appropriate attending supervision.12) Perform Damage Control procedures in the operating room and subsequent open abdomen

wound management in the intensive care unit and on the floor.

13) Manage, resuscitate, and operate on patients with would infection and intra-abdominal sepsis.14) Demonstrate competency in the performance of bedside surgical procedures such aspercutaneous tracheostomy and percutaneous gastrostomy.

15) Participate in follow-up care on an outpatient basis in the Trauma Clinic on a weekly basis.

Hepatobiliary and Transplantation Surgery - This service is the hepatobiliary transplantation serviceand performs kidney, liver and pancreatic transplantation. Other interests of the faculty includemanagement of surgical infections, and hepatobiliary surgery. There are 6 attending surgeons andseveral PAs and coordinators on the service. Residents rotate at the PGY 1 and PGY 5 level.Responsibilities and general learning objectives include:

PGY 1 - Performs initial history and physical, coordinates preoperative and postoperative care inconjunction with the senior resident, PAs and attendings. Performs simple procedures undersupervision. Upon completion of the rotation the resident is expected to:

Outline a basic plan for management of transplant patients including the principles of immuno-suppression and recognition and treatment of complications.

Discuss indications for various types of solid organ transplantation and outline appropriatepreoperative testing with regard to histocompatibility.

Describe general immunology principles and the bodys defenses against infection to include thefunction and interaction of the various classes of cellular elements, humoral defenses, and

mechanical barriers. Explain the rational use of antibiotics in surgical practice.

PGY 5 - Works with the PGY 1 and physician extenders to manage pre and postoperative patients.Responds to consults and formulates plan to present to the attending. Is responsible for patients in theintensive care units. Participates in operative procedures including harvest as directed by the attendings.Prepares material for conferences and help to coordinate medical student education. At the completionof the rotation the resident is expected to:

Comprehend surgery of the liver and biliary tract as it relates to:o Surgical anatomy of the liver and biliary tract

o Hepatic resections for benign and malignant liver lesionso Bile duct reconstruction or bypass for benign and malignant strictures.o Resection of the bile duct for cancer.o Whole organ, split liver, and live donor liver transplantation

Understand portal hypertension in terms of:o Anatomy and pathophysiology of the portal venous systemo Evaluation, treatment, and resuscitation of hemodynamically significant upper gastrointestinal

bleed

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o Medical and non-shunt surgical therapyo Non-selective, selective and percutaneous shunt therapy

Describe and assist in transplantation procedures including donor procedures.

Explain the use of immunosuppressive drugs including mechanism of action and newer trends inclinical care of transplanted organs.

Be proficient in identifying and managing complications in critically ill patients and transplantrecipients.

Define the criteria for organ and tissue donation and discuss the legal and ethical implications oftransplantation.

Night Float - Shands

The night float service at Shands is a rotation for the PGY 1 surgical resident who covers the

General/GI Surgical Service and the Surgical Oncology and Endocrinology Service. In addition, ifpatient acuity permits the resident will assist the on call team with trauma, transplantation and otheracute patient care needs.

Learning Objectives

1. To competently and expeditiously assess a patient by history, physical examination, laboratory

testing and imaging.2. To impart clinical knowledge to effectively manage postoperative patients.3. To effectively communicate to the in-house or on-call senior resident the pertinent findings of a

patient with an acute issue.4. To recognize the complications most likely to arise in the night float patient population. Follow-

up of patients with complications should come through attendance at morbidity and mortalityconference.

5. To recognize the resources available in the healthcare system at night and utilize these servicesappropriately.

6. To treat patients, staff and co-workers, especially those who may be on a long shift, with respect.7. As time permits, the resident should participate in trauma evaluations and operations.8. For those patients that will be discharged, ready all necessary documents so that the patient can

be discharged expeditiously.9. The trainee should recognize and utilize the appropriate scheduling system for patient follow-up.10. The resident should obtain good hand-off information and keep the patient records and census

information current such that an excellent sign-out to the day shift occurs.11. The resident should continuously seek out the ward nursing staff to assess patients and limit

phone calls.

12. As needed, the resident should assist others services in emergency situations.

Pediatric Surgery - This service does more than 1,500 operative procedures per year including routineand complex childhood and neonatal operations. The service has 4 attendings and besides the usualpediatric surgical expertise there is special interest in ECMO, trauma, burns, urology, airway

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management and transplantation. There are also two physician extenders who facilitate residenteducation on the service. Two PGY 1s, a PGY 2, and a PGY 4 are assigned to the service.Responsibilities and general learning objectives include:

PGY I - The first year resident manages the non-intensive care unit patients and is responsible for the

preoperative and postoperative care of the patients. The resident must understand the anatomic andphysiologic differences between children and adults and become adept at dealing with the pediatricpatient and family. At the completion of the rotation the resident should be able to:

Summarize development of the newborn throughout childhood and be able to describe commoncongenital malformations.

Outline the basic diagnosis and management of more common surgical problems such as pyloricstenosis, appendicitis, hernia, necrotizing enterocolitis.

Manage fluids and electrolytes, resuscitation, and ongoing fluid losses in each age groupencountered.

Establish IV access.

Obtain a history and perform a directed physical recognizing the changing values of normalfindings as the patients age changes.

PGY II - This resident shares with the senior resident the responsibility for answering consults,participating in the operating room, seeing patients in clinic, and managing the intensive care unitpatients. The PGY II also assists the PGY I in solving problems on the ward patients. At thecompletion of the rotation the resident should be able to:

Recognize the common and uncommon surgical diseases of infancy and childhood and have a basicplan of management including surgical options.

Manage complex perioperative problems likely to be encountered including provision of appropriate

nutritional support. Counsel families on the surgical experience and options for management of surgical illnesses in this

age group.

Perform such procedures as central line insertion, chest tube placement, ventilator management,hernia repair, gastrostomy, circumcision and other procedures as deemed appropriate by theattendings.

Manage injuries in this age group including multi-system trauma and burns.

PGY IV - Acts as the chief resident with full responsibility for the day-to-day operation of the service.Supervises the activities of the junior residents and students. Prepares conferences and presents atGrand Rounds and Morbidity and Mortality Conference. Performs routine and complex procedures

under faculty direction. At the completion of the rotation the resident should be able to:

Explain the approach to surgical management of more complex procedures including head and necklesions, thoracotomy airway and gastrointestinal, endoscopy, antireflux operations, splenectomy,diaphragmatic hernia, gastroschises, tracheoesophageal fistula utilizing both open as well asminimally invasive techniques.

Understand the prognosis and treatment of childhood tumors including Wilms, neuroblastoma,teratoma.

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Explain to patients the risk/benefit of vascular procedures, the natural history and expected surgicaloutcome of procedures such as carotid endarterectomy, aneurysm repair, endovascular procedures,and lower extremity bypass.

Outline a management plan for vascular emergencies such as acute extremity ischemia, aneurysmrupture, mesenteric ischemia.

Identify and care for deep venous thrombosis and pulmonary embolus.

Thoracic and Cardiovascular (TCV) Surgery - This is a comprehensive cardiac and thoracic servicetreating congenital and acquired diseases including patients who require heart and lung transplantation.There are 8 attending surgeons and 3 fellows in thoracic surgery as well as PGY I general surgeryresident on the service. There are also several physician extenders with extensive experience in themanagement of these patients. Responsibilities and learning objectives of the general surgery residentsinclude:

PGY I Primary responsibility is coordinating preoperative and post intensive care of patients. Theresident should manage time and coordinate the work effort such as to allow attendance in the operating

room on a daily basis. Close communication with the extenders, fellows, and attendings is important.Attendance at Tuesday morning TCV Resident Conference and Friday morning TCV General SurgeryResident Conference is mandatory. At the completion of the rotation the resident should be able to:

Describe the anatomy and physiology of the chest and its contents.

Discuss cardiac and pulmonary physiology, including control mechanisms and their regulation andthe pharmacological manipulation of these factors.

Outline the preoperative studies commonly used in patients with cardiac, great vessel or lungdisorders.

Identify and manage complications of thoracic procedures.

Explain the principles of cardiopulmonary monitoring including use of Swan-Ganz catheters and the

variables derived from such monitors. Perform simple procedures such as central line insertion, chest tubes, vein harvest/closure and

assisting in the operating room.

Burns - Surgery resident rotations on the Burn Service are provided at the PGY 1 and 2 level. Therotation involves all aspects of care of the thermally injured patient. The residents participate in initialpatient evaluation, admission to the Burn Center and all aspects of care throughout the hospital course.As an integral part of the Burn Care Team, the resident interacts with the multi-specialty ancillary staffand the Critical Care Medicine Service on a daily basis. The resident participates in all surgicalprocedures required by the burn patients and is available for outpatient burn clinic. At the completion of

the burn rotation the resident should:

Demonstrate an understanding of the concepts and pathophysiology of burn injury.

Demonstrate the ability to apply these concepts to the evaluation, resuscitation, clinicalmanagement, and rehabilitation of the burned patient

Review the criteria for adequate evaluation of a burned patient, including historicalaspects of the type of burn and subjective physical findings

Discuss an initial treatment plan for stabilization and fluid

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Outline the principles of burn shock, immunologic alteration, and bacteriologic pathologyof burned skin

Review the basic principles and controversies concerning the management of the burnwound, and describe a clinical plan for its care

Analyze the principles of systemic and local antibacterial agents in the burn wound

Explain the special circumstances created by electrical, chemical, and inhalation burninjury, and apply their relation to management

Describe the pathology and management of inhalation injury, noting its relation tomortality, morbidity, and time course of patient recovery

Assess the appearance of the burn wound in relation to its depth, bacteriologic condition,healing potential, and requirement for intervention

Describe the indications, techniques for harvest, application, immobilization, and care ofsplit- and full - thickness skin grafts

Describe and explain the following terms:o Compartment syndromeo Burn eschar contractiono Fasciotomy and escharotomy incisions and techniques

Summarize the treatment of chemical burns to include pathology, sources,decontamination, and management

Review and analyze the special circumstances, management, and rehabilitation of burnsin the pediatric patient

Summarize the activities of a specialized burn team or unit in the overall management ofthe burn patient to include the following:

o Physical therapyo Occupational therapyo Psychological counselingo Recreational therapyo Burn nursing

Provide emergency burn patient evaluation and monitoring. Determine the level of careand need for transfer to a burn facility

Implement fluid resuscitation protocols for children and adults

Select and apply appropriate dressings and antibacterials

Manage systemic effects of the burn wound in the critically injured surgical patient,considering:

o Sepsiso Gastrointestinal (GI) effectso Immunologic problemso Cardio-respiratory effects

Manage treatment of inhalation injury;o Flexible laryngotracheoscopyo Ventilator management

Manage wound therapy, including:o Eschar formation and slougho Re-epithelization

Evaluate electrical burns, including:

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o Entrance and exit woundo Cardiac, vascular, neurologic, ophthalmologic effectso Deep tissue destruction

Manage eschar contracture and edema control:o Techniques of escharotomy

o Techniques of fasciotomy

CCM

Resident Goals and Objectives

PGY2

The resident will be evaluated on the six core competencies required by the ACGME (described below),as pertains to the care of the ICU patient and the above listed goals and objectives. It is understood that

the breadth of knowledge and experience gained will be proportional to the amount of time spentrotating in the ICU as well as the effort of the resident on rounds and in reviewing appropriate readingmaterials, including textbooks, the peer-reviewed literature, and web-based educational materials.Please note that the oral examination topics are most often drawn from the ACGME competencies.

ACGME Competencies:The residency program must require its residents to obtain competence in the six areas listed below tothe level expected of a new practitioner. Programs must define the specific knowledge, skills, behaviors,and attitudes required, and provide educational experiences as needed in order for their residents todemonstrate the following:

1. Patient care that is compassionate, appropriate, and effective for the treatment of

health programs and the promotion of health:a. Perform an appropriate history and physical examination of the critically ill patient;b. Appropriateness and effectiveness of the medical plan is assessed on rounds;c. Competence in the placement of invasive monitors;d. Modified 360 degree evaluations are used to evaluate for compassionate care.2. Medical Knowledge about established and evolving biomedical, clinical, and cognate

sciences, as well as the application of this knowledge to patient care:

a. Workup of a patient with decreased urine output; b. Workup of a patient with hypotension;c. Workup and treatment of septic shock;d. Work-up of fever;

e. Initiation of antibiotics;f. Choices of mechanical ventilatory modes for ARF;g. Ventilator weaning;h. Algorithm for difficult airway in the ICU;i. Perioperative cardiac ischemia prevention and treatment; j. Workup and treatment of a patient with coagulopathy;k. How is the need for supplemental nutrition assessed and then begun;l. Principles of ATLS / ABLS / ACLS;

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m. Invasive monitoring: interpretation and trouble shooting.3. Practice-based learning and improvement that involves the investigation and

evaluation of care for their patients, the appraisal and assimilation of scientific evidence,

and improvements in patient care:

a. Learn how to use evidence-based medicine to improve patient care;

b. Become proficient at using the electronic medical record and the use of the Internet to look upmedical information;c. Evaluations of assigned lectures and rounds will be used for assessment.4. Interpersonal and communication skills that result in the effective exchange of

information and collaboration with patients, their families, and other health professionals:

a. Understand the importance of effective communication;b. Develop excellent communication skills with patients, patient families, peers, staff, andattendings;c. Assessed for on rounds with attending physicians and residents, in interactions with nursesand staff, and in family interactions.5. Professionalism, as manifested through a commitment to carrying out professional

responsibilities, adherence to ethical principles, and sensitivity to patients of diversebackgrounds

a. Understand the ethical principles of medicine and how these impact and influence the way wetreat patients. b. Understand the importance of timeliness in dictations, rounding, charting.c. Understand the need for showing sensitivity to patients ethnicity, age, life-styles, anddisabilities.d. Learn how to practice medicine with integrity and honesty.e. Assessed for on rounds with attending physicians and residents, in interactions with nursesand staff, and in family interactions.6. Systems-based practice, as manifested by actions that demonstrate an awareness of

and responsiveness to the larger context and system of health care, as well as the ability to

call effectively on other resources in the system to provide optimal health care:

a. Learn how to work with an interdisciplinary team in the care of the critical care patientincluding arranging care by consult teams.b. Learn how to approach patient care problems from a systems-based approach rather than theband-aid approach.c. Begin to develop a feel for providing cost-effective medicine without compromising patientcare;d. Appropriate resource utilization as determined by daily practice as well as discussion onrounds.

The resident will be able to recognize and treat:

I. The need for admission to the ICU care in postoperative or trauma patientsA) Physiologic instability1. Neurologic2. Respiratory3. HemodynamicB) Need for close monitoring

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1. Neurologic status2. High risk of post-op / ongoing bleeding3. Monitoring of flaps or grafts4. Poor physiologic reserve

a. Neurologic

b. Respiratoryc. HemodynamicII. Fluid management principles in postoperative / trauma / burn patients

A) ATLS / ABLSB) Maintenance requirementsC) Replacement of blood lossD) Third space lossesE) Burn injury resuscitation

1. Resuscitation formulae (Parkland, Brooke)2. Titration of resuscitation3. Indication for invasive monitoring

III Organ DysfunctionA) Neurologic System1. Confusion / agitation2. Seizures3. Hydrocephalus4. Vasospasm5. Increased ICP and herniation syndromes

B) Cardiovascular System1. Hypotension2. Hypertension3. Arrhythmias4. Cardiac arrest (ACLS)5. Differential diagnosis and treatment of shock states

C) Respiratory System1. Hypoxia2. Hypercarbia3. ALI / ARDS4. Airway Compromise Understand different methods for securing the airway

a. Endotracheal intubation with and without drugs b. Awake fiberoptic intubationc. Laryngeal mask airwayd. Indications for tracheostomy

i. Cricothyrotomyii. Surgical tracheostomy

5. Understand the various modes of ventilatory supportD) Renal System

1. Differential diagnosis and treatment of oliguria2. Azotemia3. Common electrolyte abnormalities

i. Hyper / hyponatremia

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ii. Hyper / hypokalemiaiii. Hyper / hypocalcemiaiv. Hyper / hypophosphatemiav. Hypomagnesemia

4. Renal replacement therapy

5. Acid-Base DisordersE) Hepatic System1. Jaundice2. Coagulopathy3. Shock liver

F) Hematologic System1. Anemia2. Thrombocytopenia3. Coagulopathy

G) Endocrine System1. Adrenal insufficiency

2. Thyroid disorders3. Diabetes Insipidus4. Diabetes mellitus / and glycemic control5. SIADH6. Cerebral salt wasting syndrome

IV. Prevention and Management of Infectious DiseasesA) Evaluation and workup of feverB) Antibiotic selection

1. Initial choice2. Narrowing antibiotic focus based upon sensitivities3. Antimicrobial drug monitoring4. Duration of therapy

C) Prevention and Treatment of common infections1. Ventilator-associated pneumonia (VAP)2. Catheter-related bloodstream infection3. UTI4. Wound infection5. Peritonitis / Intra-abdominal abscess6. Meningitis7. Sepsis / septic shock

D) Surgical ProphylaxisV. Nutritional Depletion

A) Evaluation of nutritional statusB) Enteral NutritionC) Parenteral Nutrition

VI. The Indications for Blood Component TherapyA) Packed RBCsB) PlateletsC) Fresh Frozen PlasmaD) Cryoprecipitate

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E) Recombinant Factor VIIaF) Bleeding abnormalitiesG) Transfusion triggers

The resident will:

VII. Understand Indications and Techniques for Procedures in the ICUA) CapnographyB) Arterial lineC) Central venous lineD) Pulmonary artery catheterE) Lithium dilution cardiac output (LiDCO)F) Esophageal Doppler MonitorG) EchocardiographyH) Transvenous pacerI) External pacer

J) Chest tubeK) BronchoscopyVIII. Practice Preventive / Proactive Medicine

A) DVT prophylaxisB) Stress ulcer prophylaxisC) Pulmonary toilet / bronchodilators / VAP prophylaxisD) Perioperative heart rate and blood pressure controlE) Renal protection before dye load

IX. Understand Methods to Provide Sedation and AnalgesiaX. Understand Appropriate Use and Monitoring of Neuromuscular BlockadeXI. Understand the Risks of Transporting a Critically Ill PatientXII. Rapidly Recognize Postoperative Complications

A) Postoperative hemorrhageB) Anastomotic leadC) Wound infectionD) AbscessE) Poor graft function

XIII. Understand Management of Primary / Secondary / Tertiary Survey in Traumatic InjuryA) Traumatic Brain InjuryB) Head and Neck InjuriesC) Thoracic InjuriesD) Abdominal and Pelvic InjuriesE) Extremity InjuriesF) Pregnant Trauma patient

XIV. Understand Critical Care Issues in PregnancyA) Pre-eclampsia / EclampsiaB) Peripartum HemorrhageC) Pulmonary and amniotic fluid embolism

D) Peripartum cardiomyopathy

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Orthopaedics - The residents may rotate on the orthopedic service at the PGY I level. The resident isassigned to the unique Orthopaedic Oncology service but also attends and participates in all of the

conferences for the Department. The PGY I is exposed to a variety of soft tissue and bone neoplasms.There is also opportunity for exposure to sports and other orthopedic injuries while on the service. Atthe completion of the rotation the resident is expected to:

Describe the gross anatomical structures of the skeletal system.

Understand the basic physiology for different types of musculoskeletal disease including congenital,developmental, degenerative, neoplastic and traumatic.

Discuss the use of imaging modalities in diagnosing such orthopaedic pathology as tumors,extremity injuries and spinal injuries.

Outline the management of soft tissue and bone tumors.

Participate in the operating room as directed.

Explain the basics of physical therapy and rehabilitation to maximize functional recovery.

Otolaryngology - Residents may rotate on the otolaryngology service at the PGY I level. The rotationis intended to teach the basics of care for the patient with head and neck disorders including head andneck cancer, obstructed airways and infectious problems. The resident is expected to perform a directedhistory and physical and participate in the operating room. At the completion of the rotation, theresident is expected to:

Be familiar with the unique anatomy of the head and neck region.

Perform a comprehensive head and neck examination and a directed history.

Discuss the management of such conditions as epistaxis, facial trauma, sinusitis, epiglottitis, middle

ear infections, mastoiditis. Explain the appropriate steps in the diagnosis of suspected head and neck cancer including the

finding of a solitary node, oral ulcer, or laryngeal lesion.

Outline the treatment modalities available to treat head and neck malignancies including radiation,chemotherapy and surgery and their application.

Perform simple procedures and assist at operation.

Urology - Residents may rotate on the urology service during the PGY I year. The resident is expectedto perform appropriate history and physicals on the urology inpatients and to participate in outpatientclinics. Emphasis is placed on learning to manage routine and emergency genitourinary problems seenby the non-specialist and to know when to refer for specialty care. Residents are expected to attend all

Urology conferences and assist in the operating room. At the completion of the rotation, the residentshould be able to:

Perform a complete urologic examination with emphasis on the genitals and rectal.

Explain the appropriate diagnosis and treatment of scrotal masses, prostatism, hematuria, torsion ofthe testicle, hydrocele.

Describe the normal anatomy and physiology of the male and female genitourinary system withemphasis on genitourinary system as it relates to disease processes seen in general surgery.

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Outline the treatment and prognosis for cancer of the genitourinary system including carcinoma ofthe kidney, bladder, testicle and prostate.

Discuss the causes of sexual dysfunction and options for the patient with impotence.

Be familiar with suprapubic cystostomy, passage of various types of urinary catheters, andmanagement of genitourinary injuries.

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Discuss the economic and psychosocial issues associated with malignant and life altering chronicdiseases and be able to use the resources in the institution to manage these patients in acompassionate and cost effective manner.

Gain proficiency in the operative skills associated with the care of patients with routine surgicalillnesses, especially those of the gallbladder and of hernia repairs.

PGY V - The chief resident assumes considerable responsibility and autonomy on this rotation. Thechief is expected to take personal responsibility for the patients on the service and to be available tocompletely care for these patients. The chief is supervised by and has frequent contact with theattending. The chief prepares conference material and must be involved in the daily teaching of thejunior residents and students. At the completion of the rotation the resident should be able to:

Manage the entire spectrum of patients likely to be encountered in the practice of general surgery,working with others in the integrated delivery of health care to the patient.

Understand issues of cost containment, patient self-determination and medical care delivery systemsthat impact patient care.

Be proficient in the operative techniques of general surgery. Understand the scientific basis of clinical decision making, read the literature critically and be

committed to remaining abreast of advances in the field.

Teach the principles of general surgery to junior residents and students.

Demonstrate commitment to the highest moral and ethical values of the profession.

Vascular Surgery - This service provides the primary operative vascular surgical experience for theresidency. There are three vascular faculty who share responsibility for the service and an experiencedphysicians assistant and nurse. The conference schedule is fully integrated with the service at ShandsHospital. Residents are exposed to all of the common problems encountered in the practice of vascularsurgery. Residents rotate at the PGY I and IV level with the PGY IV acting as chief resident.

Responsibilities and general learning objectives include:

PGY I - The first year resident does patient work-ups, sees patients in clinic, cares for the patients onthe ward and responds to consults. The PGY I is expected to participate in the operating room asworkload permits and to perform such procedures as amputations and skin grafts. At the completion ofthe rotation the resident should be able to:

Perform a directed history and physical emphasizing the multiple problems likely to be seen in thispopulation.

Describe the preoperative work-up for patients with common vascular problems such as carotiddisease, aneurysm and lower extremity ischemia including the use of the noninvasive laboratory and

invasive techniques. Manage the routine postoperative recovery of these patients and recognize complications such as

myocardial ischemia, wound breakdown and pulmonary problems.

Perform central lines and simple operative procedures under supervision.

Explain the hemodynamics of the vascular tree and the implications for therapy.

Understand the anatomy of the vascular system and be able to interpret angiograms and CT scans asthey apply to the vessels.

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PGY IV - The chief on the service is expected to manage the day-to-day problems and appropriatelyschedule patients for operation with the supervision of the faculty. The chief performs or assists thejunior residents in all operations under the supervision of the attendings. The chief prepares pre-operative conference and Morbidity and Mortality Conference materials and presents at theseconferences. The chief is expected to have a treatment plan and be able to justify it with literature. At

the completion of the rotation the resident is expected to:

Outline the indications, appropriate work-up and surgical options for patients with carotid stenosis,aneurysms, claudication, limb threatening ischemia, acute ischemia, venous insufficiency and othercommon vascular problems.

Perform the operative approach to the major vessels and do vascular anastomoses to large and smallvessels.

Manage pre and postoperative patients and recognize and treat complications.

Discuss the appropriate follow up of vascular grafts and outline procedures for the failing graft.

Explain the role of angioplasty, stents and lysis in the care of the vascular patient.

Teach the junior residents and students the basics of patient care and vascular physiology.

Critical Care - The SICU/CTICU admits patients from all of the surgical services and the PGY Iassigned to the ICU should consider him or herself a member of each of the other services byparticipating in rounds with the other services and assisting in the management of the patients. The ICUteam acts as consultants, as well as insure patients are recovered as expeditiously as possible. Thedirector of the unit (Dr. Carter) will make rounds daily and the resident is expected to have a treatmentplan for all of the patients consistent with the plans of the primary team. The resident coordinatesadmissions and discharges from the unit in conjunction with the director and head nurse. At thecompletion of the rotation the resident should be able to:

Place monitoring lines and interpret the data obtained.

Understand the pathophysiology of various forms of shock and appropriate treatment. Recognize the risk factors for nosocomial infection and their treatment.

Explain the indications and the pharmacokinetics of commonly used drugs such as lidocaine,diltiazem, amiodarone, epinephrine.

Manage airways and ventilatory equipment.

Discuss current guidelines for transfusion therapy.

Appreciate issues of resource utilization, DNR orders, advance directives, and futility.

Plastic Surgery - This service treats a large number of patients with cutaneous malignancies, handproblems and chronic wounds. There are 4 faculty and one fellow in plastic surgery. There is also aPGY I general surgery resident who is responsible for work-ups, performing resections of cutaneous

malignancies and assisting in more complex reconstructions. At the completion of the rotation theresident should be able to:

Perform a directed history and physical examination focusing on issues pertinent to diseaseprocesses and congenital abnormalities seen by plastic surgeons including examination of the upperextremity and head and neck.

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Discuss commonly occurring congenital anomalies of the heart and lungs and their correction.

Outline the treatment of thoracic injuries and the indication for further diagnostic or therapeuticinterventions.

Lake City VA Hospital

Ambulatory Surgery - The Lake City VA is a community facility located approximately 45 miles northof Gainesville. The surgery service there treats patients with routine surgical problems and has an activeendoscopy suite directed by surgeons. Residents rotate to Lake City at the PGY I level. Responsibilitiesand general learning objectives include:

PGY I - As on other general surgery services, the PGY I is responsible for initial work ups, care of thepostoperative patient and for assisting or performing cases in the operating room under the direction ofthe attendings. At the completion of the rotation the resident is expected to:

Demonstrate knowledge of anatomy and pathophysiology of common surgical problems such as

hernias, skin lesions, appendicitis, perianal disease. Efficiently gather data and apply that information to the management of patients in the inpatient and

outpatient setting.

Learn the basics of responding to a request for surgical consultation by other services.

Participate in endoscopic procedures and perform those deemed appropriate by the attendings undersupervision.

Interact with other providers in a professional and mature manner that fosters improved care of thepatient.

West Palm Beach VA Medical Center

PGY 2 Resident

To competently assess general surgical and surgical sub-specialty patients by taking an accuratehistory, performing a physical examination and obtaining necessary laboratory and imaging data.To integrate clinical presentation and data to develop a treatment plan for patients.To gather, read and interpret the medical literature necessary to manage patients with generalsurgical and sub-specialty surgery conditions.To effectively communicate to other health care providers and students the clinical findings andpertinent data from the literature regarding patient treatment.

To participate in the operative care of patients and develop requisite motor skills to competentlycomplete surgical procedures.To participate in weekly Surgery Grand Rounds Conference via telebroadcasting.To assess patient outcomes for morbidity and mortality conference in the context of the NationalQuality Surgical Improvement Program data.To prepare and participate in Surgery 201 via teleconference.To participate in the monthly multidisciplinary tumor board and Morbidity and Mortality Conferenceat the West Palm Beach VA.

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To demonstrate exemplary professional conduct in interactions with patients, staff and faculty whilerunning the service.

Community Surgery at AGH

The Community Surgery rotation at Alachua General Hospital (367-beds) is designed to provide anapprentice-type model of training where residents have a close working relationship with a singlecommunity surgeon. The clinical material will include the typical bread and butter experiences of acommunity-based general surgeon (i.e. abdomen, alimentary tract, shin and soft tissue, and breastdisease). Residents will rotate at AGH at the PGY1 and PGY3 level with increasing resident exposure tothe work-up and management of common general surgical problems

Goals: Demonstrate the knowledge, skills and attitudes essential to the practice of general surgery in acommunity-based setting.

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SHANDS RESEARCH LABORATORY

As it is currently configured, two to three categorical residents each year will be in the laboratory forone or two years. Two of the residents will enter the laboratory after the second year and one after thethird year. This is subject to change due to funding and the availability of laboratories to place the

resident. The chairman and program director will discuss the laboratory year with the categoricalresidents during the first and second year and make every effort to match the residents wishes with theneeds of the program, but this is not guaranteed. Occasionally residents may desire two or three years inthe laboratory but this also is not guaranteed and is subject to funding and manpower needs. Residentsmust make their wishes known to the program director early in the second half of the first year andcomplete an application by October 1 of their PGY2 year.

The laboratory experience is no different from any other rotation and has its own responsibilities andgeneral learning objectives. These include:

Complete dedication to the laboratory experience as directed by the laboratory director. The

laboratory year is not any less intense than any of the clinical years and, to be productive, theresident must be willing to put in the effort. It is expected that the residents in the laboratory willbehave in a collaborative manner with other residents and faculty in the department and be willing toassist at any task assigned. This will include occasional call nights and some unscheduled clinicalduties. The resident is to learn and apply the scientific method under the direction of the laboratoryattending. This should include identifying a problem, formulating a hypothesis, performing aliterature review, designing and performing experiments, analyzing data, writing results andpresenting results at regional and national meetings.

The resident should become proficient in a number of laboratory skills. These may include tissueculture, small animal and primate surgery, molecular biology, immunochemistry, proteinpurification, statistical and data analysis, and other skills that may be applied to a variety of

problems. It is anticipated that the resident will submit abstracts for presentation, prepare manuscripts for peer

reviewed publication and discuss their findings with other members of the department and College.

It is expected that the resident, at the end of the laboratory experience, will be able to identify arelevant question, formulate a hypothesis, describe a method to answer the question, be able toanalyze the results of that inquiry and communicate these findings. The resident should also be ableto identify external funding sources and prepare an application for peer review. This process willbenefit the resident regardless of whether or not the resident pursues research as a career.

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ACGME CORE COMPETENCIES

The ACGME has determined that all physicians graduating from an accredited program should beproficient in six areas of specialized skills. The surgery program at the University of Florida providesthe needed educational experiences through various rotations, conferences and other instruction to meet

these requirements. The evaluation system is designed to determine the residents progress in attainingproficiency in these areas.

The specific language from the program requirements is included below:

Residents must become competent in the following six areas at the level expected of a surgicalpractitioner. Training programs must define the specific knowledge, skills, and attitudes required andprovide the educational experience for residents to demonstrate:

1. Patient Care that is compassionate, appropriate, and effective for the treatment of healthproblems and the promotion of health.

Surgical residents must:

a. demonstrate manual dexterity appropriate for their training level.

b. be able to develop and execute patient care plans.

2. Medical Knowledge about established and evolving biomedical, clinical, and cognate (eg.epidemiological and social-behavioral) sciences and the application of this knowledge topatient care.

Surgical residents are expected to:

a. critically evaluate and demonstrate knowledge of pertinent scientific information.

3. Practice-Based Learning and Improvement that involves investigation and evaluation of theirown patient care, appraisal and assimilation of scientific evidence, and improvements inpatient care.


a. critique personal practice outcomes.

b. demonstrate a recognition of the importance of lifelong learning in surgicalpractice.

4. Interpersonal and Communication Skills that result in effective information exchange andteaming with patients, their families, and other health professionals.


a. communicate effectively with other health care professionals.

b. counsel and educate patients and families.

c. effectively document practice activities.

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5. Professionalism, as manifested through a commitment to carrying out professionalresponsibilities, adherence to ethical principles, and sensitivity to a diverse patientpopulation.


a. maintain high standards of ethical behavior.

b. demonstrate a commitment to continuity of patient care.

c. demonstrate sensitivity to age, gender and culture of patients and other health careprofessionals.

6. Systems-Based Practice as manifested by actions that demonstrate an awareness of andresponse to the larger context and system of health care and effectively call on systemresources to provide optimal care.


a. practice high quality, cost effective patient care.

b. demonstrate a knowledge of risk-benefit analysis.

c. demonstrate an understanding of the role of different specialists and other healthcare professionals in overall patient management.

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The following tables summarize the Departmental teaching and assessment methods for the 6 ACGME core competencies:ACGME Core Competencies (Educational Methods)

COMPETENCY

AttendingRoun

ds

OperatingRoom

Clinic

SkillsLaborator

ies

M&

MC

onference

GrandRounds

ChairsConference

PGYLevel-specific

Courses

S

i

S

i f i

Patient Management Capabilities

Technical SkillsX

XX

XX

X X XX

XX

XX

Fund of Knowledge

Critical Thinking Skills

X

X

X

X

X

X

X X

X

X

X

X

X

X

X Evidence-Based Practice

Teaching Proficiency

XX

XX

XX

X X X X X

Effective Communication Skills

Teamwork Ability

XX

XX

XX

X X X X X

Integrity

Dependability & Punctuality

Respect Patient Confidentiality

XXX

XXX

XXX

XXX X

XX

XX

Other Health Care Workers

Cost-Effective Patient Care

XX

XX

XX X

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ACGME Core Competencies (Assessment Methods)

COMPETENCYn-

ne

Faculty

360

Evaluation

MockOrals

ABSITE

ACGME

CaseLog

Skills

Evaluation

M&

M

Conference

Scholarly

Activity

Records

Completion

PATIENT CARE

Patient Management Capabilities

Technical Skills

XX

X X XX

XX

XX

X

MEDICAL KNOWLEDGE

Fund of Knowledge

Critical Thinking Skills

X

X

X X X

XPRACTICE-BASED LEARNING & IMPROVEMENT

Evidence-Based Practice

Teaching Proficiency

XX X

X X X

NTERPERSONAL & COMMUNICATION SKILLS

Effective Communication Skills

Teamwork Ability

XX

XX

XX

PROFESSIONALISM

Integrity

Dependability & Punctuality

Respect Patient Confidentiality

XX

X

XX

X

XX

XX

XX

SYSTEM-BASED PRACTICE

Other Health Care Workers

Cost-Effective Patient Care

XX

X

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The American College of SurgeonsCode of Professional Conduct*

As Fellows of the American College of Surgeons, we treasure the trust that our patients have placed in us because trust isintegral to the practice of surgery. During the continuum of pre-, intra-, and postoperative care we accept responsibilities to:

Serve as effective advocates for our patients' needs.

Disclose therapeutic options, including their risks and benefits.

Disclose and resolve any conflict of interest that might influence decisions regarding care.

Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.

Fully disclose adverse events and medical errors.

Acknowledge patients' psychological, social, cultural and spiritual needs.

Encompass within our surgical care the special needs of terminally ill patients.

Acknowledge and support the needs of patients' families.

Respect the knowledge, dignity, and perspective of other health care professionals.

Our profession is also accountable to our communities and to society. In return for their trust, as Fellows of the AmericanCollege of Surgeons, we accept responsibilities to:

Provide the highest quality surgical care.

Abide by the values of honesty, confidentiality, and altruism.

Participate in lifelong learning.

Maintain competence throughout our surgical careers.

Participate in self-regulation by setting, maintaining, and enforcing practice standards.

Improve care by evaluating its processes and outcomes.

Inform the public about subjects within our expertise.

Advocate strategies to improve individual and public health by communicating with government, health careorganizations, and industry.

Work with society to establish just, effective, and efficient distribution of health care resources.

Provide necessary surgical care without regard to gender, race, disability, religion, social status or ability to pay.

Participate in educational programs addressing professionalism.

As surgeons, we acknowledge that we relate to our patients when they are most vulnerable. Their trust, and the privileges weenjoy, depends upon our individual and collective participation in efforts that promote the good of both our patients andsociety. As Fellows of the American College of Surgeons we commit ourselves and the College to the ideals ofprofessionalism.

43Adapted from http://www.facs.org/fellows_info/statements/stonprin.html#anchor116209
http://www.lnmonnmd.com/images/logo-acs.jpg


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CONFERENCES

Residents are expected to attend all conferences at the departmental level. At a minimum, this means85% of the conferences. Attendance is recorded and will be part of the residents evaluation as part ofthe ACGME Professionalism core competency. Residents should also attend the conferences of the

service to which they are assigned. The conference program is designed to provide a didactic andinteractive forum to augment the residents reading and clinical experience. Failure to attendconferences limits the residents ability to be exposed to the wide breadth of problems seen in surgicalpractice. Residents must be on time for conferences and it is requested that residents turn down thevolume on their beepers or put them on vibrator mode if possible so that there is the least

Surgical Associate Manual 07 08

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