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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 1 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: 2 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 3 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 4 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 5 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. 6 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 7 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) 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) Attending evaluation of the resident In Service examination scores Ancillary providers evaluation of the resident 8 Assessment Method (Program Evaluation) 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 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). 9