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MERCY MEMORIAL HOSPITAL SYSTEM
FAMILY MEDICINE RESIDENCY
GENERAL SURGERY – INPATIENT AND OUTPATIENT CURRICULUM
(PGY1, PGY2)
Description of Educational Experience
Patients and their families need to be able to make well-informed decisions about when,
where, and from whom to get their surgical care. They often rely on their family
physician to assist in determining the answers to these questions. Primary care providers
need to be prepared to provide such information, to understand “best practices” and
quality improvement efforts that will benefit their patients. The General Surgery
experiences, both inpatient and ambulatory, are designed to provide training in
preoperative assessment, common surgical principles and techniques, and management of
postoperative complications when they occur. Residents develop competency in their
surgical knowledge and skills, in health care advocacy, and in helping patients and their
families navigate through the stress inherent in going through a surgical procedure.
All PGY-1 residents are scheduled for one 4 week block of primarily inpatient surgical
training under the supervision of general surgeons. The experience will include the
emergency consultative assessment of surgical patients in the Emergency Department,
and assisting in operative and postoperative care of patients within the hospital. The
PGY-2 residents complete a primarily outpatient-based rotation in a surgeon’s office for a
period of one 4 week block. Residents are expected to attend relevant surgery
conferences as scheduled.
Residents will be expected to demonstrate an understanding of the evaluation, diagnosis
and management of common general surgical problems presenting to Family Physicians.
Pre-operative patient evaluation, common post-operative care issues, and basic surgical
techniques will be covered. The General Surgery curriculum is designed to assist
resident appreciation of surgical principles and technique and to develop facility in
relevant procedural skills. Family Medicine residents need to be mindful of their role in
longitudinal care of patients needing surgical interventions, and their vital role pre- and
postoperatively.
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health.
Competencies
Residents are expected to:
 Gather essential and accurate information about the surgical patient
 Develop and carry out a patient management plan based on patient information,
evidence based care and clinical judgment
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Objectives
PGY-1 Residents will be able to:
 Obtain a detailed history and perform a through physical exam appropriate for the
history
 Demonstrate understanding of the following fundamental principles of surgery and
their application to patient care:
1. Basic concepts of infection control in surgical practice, asepsis and sterile
technique
2. Patient monitoring
3. Management of fluid and electrolyte balance
4. Estimation of blood products requirements
5. Temperature control
6. Patient mobility
7. General nutrition management pre and post-operatively
8. Drains and suction
9. Routine postoperative care for the hospitalized patient, including
management of postoperative pain and complications:
a. Postoperative infection
b. Hemorrhage
c. Transfusion reaction
d. Pulmonary embolism and thrombophlebitis
e. Oliguria
f. Ileus
g. Shock
PGY-2 Residents will be able to:
 Demonstrate basic clinical skills with the following:
1. Preoperative care
2. Postoperative care
3. Basic surgical principles and asepsis
4. Handling of tissue
5. Technical skills for assisting in OR
6. History and general physical examination skills
 Perform common surgical and wound care procedures under supervision, which
may include:
1. Casting and splinting
2. Application of commercial drainage devices
3. Application of splinting devices
4. Joint injections
5. Joint aspirations
6. Fracture reductions
7. Nerve blocks
8. Wound debridement
9. Incision and drainage
10. Wound dressings:
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


a.
Packing
b.
Wet to dry
c.
Commercial preparations
Educate patients and families about preoperative and postoperative care including
preparation prior to procedure, postoperative discharge instructions, ongoing
wound care, medications, pain management, and follow-up care
Educate patients and families about preoperative and postoperative care including
preparation prior to procedure
Understand the psychosocial effects of surgical interventions on the patient
and/or caregivers
Medical Knowledge
Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical,
epidemiological, and social-behavioral sciences, as well as the application of this
knowledge to patient care. The following objectives represent the knowledge and skills
necessary to provide appropriate care to the adult surgical patient while on this rotation.
Topics are not meant to be exclusive, but rather represent those diagnoses most often
encountered while on rotation.
Competencies
Residents are expected to:
 Demonstrate an investigatory and analytical approach to clinical situations in
general surgery
 Know and apply the basic and clinically supportive sciences which are appropriate
to their discipline
Objectives
PGY-1 Residents will be able to:
 Demonstrate basic knowledge and motor skill on the following topics:
1. Pre-operative history and physical
2. General care of the post-operative patient including pain management
3. General wound management
4. Basic surgical skills (handling instruments, suturing and knot tying)
5. Diagnosis and management of common head and neck tumors including
diagnosis and management of thyroid, parathyroid enlargement and
tumors, and assessment of parotid mass
6. Breast, skin and soft tissue:
a. Recognize breast abnormalities: dimpling, changes in symmetry,
palpable mass, etc.
b. Diagnosis and management of cellulitis
c. Diagnosis and management of serious hand infections
d. Knowledgeable regarding laceration management
7. Thorax:
a. Diagnosis and management of pneumothorax
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8. Gastrointestinal tract and abdomen:
a. Diagnosis of gallbladder and extra-hepatic and biliary systems
pathology that may require surgical intervention
b. Diagnosis of pancreatic disease that may require surgery
c. Recognize indications for feeding gastrostomy or jejunostomy
d. Recognize the need for hyperalimentation (enteral, parenteral)
e. Describe and assist in management of gastrointestinal tract
problems:
i.
Esophageal neoplasm
ii.
Diaphragmatic hernias
iii. Stomach: ulcers, tumors, gastric outlet obstruction, hiatal
hernia
iv.
Small and large intestine: neoplasms, inflammatory bowel
disease, intestinal obstruction, appendicitis, diverticulitis
v.
Diagnosis and assistance in the management of peritonitis
and intra-abdominal abscess
9. Vascular system:
a. Diagnosis of vascular disease, which may require surgery
(varicose veins, venous stasis ulcers, arterial insufficiency,
thrombosed external hemorrhoids)
b. Describe the risks, classification and management of abdominal
aortic aneurysm
10. Trauma and thermal injury:
a. Diagnose, classify, and refer for surgical treatment and assist in
the postoperative management of burns
b. Interpret CVP readings; recognize indications for central line
placement
c. Recognize indications for lifesaving measures such as
cricothyroidotomy, needle thoracotomy, and pericardiocentesis
11. Bleeding and transfusion:
a. Indications for transfusion of blood and blood products
b. Operative considerations in patients on anticoagulants
c. Management of transfusion reactions
d. Alternatives to transfusion/blood products
12. Care in special circumstances:
a. Describe the unique surgical considerations in special
populations:
i.
The elderly surgical patient
ii.
The pediatric surgical patient
iii. The pregnant surgical patient
13. Review considerations regarding organ procurement
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PGY-2 Residents will be able to:
 Demonstrate basic knowledge and motor skill on the following topics:
1. Knowledge of basic surgical principles such as:
a. Wound physiology, care and healing process
b. Surgical anatomy
c. Lines of Langerhans
d. Suturing techniques
e. Incision and drainage
f. Simple excisions and punch biopsy
g. Aspiration
h. Injection
i. Cauterization/electrodessication
j. Greater mastery in the diagnosis and management of surgical
disorders
2. Wound classification systems:
a. Infectious Diseases Society of America classification system for
foot infections in diabetic patients
b. Wound classification – Non-pressure wound (partial thickness,
full thickness)
c. Wound classification – Pressure ulcer wound (Stages 1-4)
3. Preoperative assessment:
a. Recognition of appropriate surgical candidates
b. Surgical risk assessment
c. Antibiotic prophylaxis
d. Patient preparation prior to specific procedure
e. Informed consent
4. Intraoperative care:
a. Sedation/Anesthesia
i.
Conscious sedation
ii.
Local, regional anesthesia
iii. General anesthesia
b. Basic principles of asepsis and sterile technique
c. Preparation and draping of the operative field
d. Incision and dissection
e. Exposure/retraction
f. Hemostasis
g. Patient monitoring
h. Fluid management
i. Use of basic surgical instruments
j. Wound closure
i.
Placement of wound suction devices and drains
ii.
Technique selection – ligature, staples, adhesives
iii. Suture selection
iv.
Dressings
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5. Postoperative Care:
a. Observation principles for level of sedation/anesthesia
b. Criteria for discharge
c. Wound care
d. Pain management
e. Compartment syndrome/fasciotomy
f. Follow-up care
g. Common complications
h. Suture, staple and/or drain removal
6. Pharmacological management and complimentary/alternative medicine
management of postoperative or postprocedure pain
Practice-based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients,
to appraise and assimilate scientific evidence, and to continuously improve patient care
based on constant self-evaluation and lifelong learning.
Competencies
Residents are expected to develop skills and habits to be able to :
 Use information technology to optimize learning
 Incorporate formative evaluation feedback into daily practice
Objectives
PGY-1 Residents will be able to:
 Demonstrate ability to locate and use patient care information from available
online resources
 Improve skills based on feedback evident in documentation, procedural
performance and interpersonal communications
PGY-2 Residents will be able to:
 Continue to master technology resources during sessions to support and improve
their own learning (PDA, on-line resources, etc.)
 Apply evidence – based medicine to patient care
 Describe elements of cost-effective, non-emergency surgical care
Systems-based Practice
Goal
Residents must 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.
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Competencies
Residents are expected to:
 Work in inter-professional teams to enhance patient safety and improve patient
care quality
 Coordinate patient care within the health care system relevant to general surgery
Objectives
PGY-1 Residents will be able to:
 Utilize social workers and case care managers in patient care
 Use hospital based standardized order sets for the general surgical patient
PGY-2 Residents will be able to:
 Identify elements key to patient safety such as the National Patient Safety Goals
for accuracy of identification and infection control
 Apply evidence-based, cost-conscious strategies to prevention, diagnosis, and
disease management
 Interact with and utilize multidisciplinary healthcare providers and community
resources to provide effective, comprehensive patient care
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities
and an adherence to ethical principles.
Competencies
Residents are expected to demonstrate:
 Compassion, integrity, and respect for others
 Respect for patient privacy and autonomy
Objectives
PGY-1 Residents will be able to:
 Appropriately and ethically use electronic health information systems
 Follow HIPPA and hospital policies concerning patient privacy
PGY-2 Residents will be able to:
 Demonstrate respect, compassion, and integrity
 Reliably complete assignments and be accountable for own actions
 Commit to excellence, lifelong learning and professional development
 Adhere to professional and personal ethical principles
 Follow HIPPA and hospital policies concerning patient privacy
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Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the
effective exchange of information and teaming with patients, their families, and
professional associates.
Competencies
Residents are expected to:
 Communicate effectively with physicians, other health professionals, and health
related agencies
 Act in a consultative role to other physicians and health professionals
Objectives
PGY-1 Residents will be able to:
 Coordinate care of the patients on the surgical service with other health care
providers
 Help in providing consultative surgical services while on the general surgery
rotation
PGY-2 Residents will be able to:
 Provide care that is sensitive to the patient’s or caregiver’s concerns and anxieties
regarding surgical interventions
 Communicate effectively to patients and families in a professional, compassionate,
culturally effective and patient-centered manner that encourages questions,
discussions and mutual goal setting
 Understand the importance of communication in improving patient safety,
decreasing medical errors, and minimizing the risk of malpractice claims
 Evaluate patient/family’s level of literacy and the effectiveness of professional
communication when providing information about diagnosis, treatment, follow-up,
and coordination of care and resources
Learning Opportunities (residents)
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Direct instruction by attending physician
Direct care of the general surgical patient
Working with ancillary providers (wound care nurses, CRNAs, social workers,
etc.)
Assessment Method (residents)
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Attending evaluation of the resident
In Service examination scores
Ancillary providers evaluation of the resident
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Assessment Method (Program Evaluation)
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Resident evaluation of the program
Resident evaluation of the attending
Annual program review
Level of Supervision
The resident is under the direct supervision of the attending physician.
Educational Resources
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Online physician medical resources through DynaMed, McGraw-Hill's
AccessSurgery, etc.
ACGME Website for Surgery Menu & Program Requirements: Effective Date
2005. Accessed April 5, 2007 at
http://www.acgme.org/acWebsite/downloads/RRC_progReq/440pr1105.pdf
American Academy of Family Physicians Recommended Curriculum Guidelines
for Family Medicine Residents in the Care of the Surgical Patient. Last Revision
1/2004.
Lavery LA, Armstrong DG, Murdoch DP, Peters EJ, Lipsky BA. Validation of the
Infectious Diseases Society of America's diabetic foot infection classification
system. Clin Infect Dis. 2007 Feb 15; 44(4):562-5. Epub 2007 Jan 17.
PMID: 17243061 (PubMed - indexed for MEDLINE).
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