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Surgery
Surgical experiences are also part of the required and elective curriculum for ENT, ophthalmology, dermatology, orthopedics, emergency care, gynecology, etc. www.altoonahospital.org/trauma/
Altoona Family Physicians The Family Physician is often the first physician to interact with a patient who has a surgical diagnosis. The comprehensive care delivered by family physicians spans the preoperative, perioperative and postoperative time frames. Surgical care is defined as the body of knowledge, skill and attitudes required and necessary to evaluate and manage conditions and disorders requiring operative intervention. Altoona Family Physicians Surgery Rotation Description: The General Surgery rotation is 2 months in duration and is divided into Surgery I, which occurs during the first year and Surgery II, which occurs during the second year. Surgery I is a 1 month block rotation usually occurring early in the resident’s first year. The resident spends this month with one of several general surgeons who rotate as attending physicians for this learning experience. During the first week of Surgery I, time is spent in a pre-operative experience with anesthesia personnel. Intubation, line placement and preoperative evaluation is learned. For 2 half days during that time, one on one procedural training relevant to general surgery is taught utilizing a high tech procedural manikin. For the balance of the rotational experience, time is allocated between inpatient and outpatient surgeries, inpatient rounding and post-operative care, office surgeries and follow-up with the surgical attending and, of course, longitudinal care on the resident’s own family medicine inpatient panel at the family medicine center. Surgery II is also a 1 month block rotation but it occurs in the second year of the curriculum. The resident spends this month with the Lexington surgical group. These attendings are all general surgeons who are also trained and supportive of the hospital’s trauma program. During the first week of Surgery II, time is spent in the ARHS wound clinic at the Bon Secours campus. This clinic is staffed by multiple general surgeons who manage troublesome wounds, do minor procedures and employ state of the art wound care modalities for both surgical and non-surgical wounds. The resident is an active participant and learner in this clinic. The balance of the rotation is spent with time allocated between inpatient and outpatient surgeries and inpatient rounding. Several half days of outpatient surgical clinic are also included. As well, the resident sees his/her own panel of patients at the family medicine center on those appointed half days. The exact structure of each of the above rotations can be found utilizing the current HCFA Resident Tracking Sheets. First Day Instructions: First day of Surgery I go to the Anesthesia Department in the OR. First day with the surgeon in hospital—call or page the surgeon to arrange a meeting time and place. First day of Surgery II go to Wound Clinic at the Bon Secours campus. First day with the surgeon in hospital—call or page to arrange a meeting time and place. Residency contacts: Julie Fochler, Dr. Art Morrow—both extension 2020 Contacts—Surgery I: Dr. Magee-946-0891, Dr. Newlin-943-7040, Anesthesia—Dr. Falcone or Diane Andersen- Ext. 7811 or 2103, Flo Eberhart (procedures) 935-2042. Contacts—Surgery II: Drs. Lampard/Siddiqui-943-7040, Wound Clinic-Ellen Schraff, RN—Ext. 2793 Competency Based Rotational Goals and Objectives Patient Care Goal Residents will, at the completion of this rotation, be able to provide patient care related and relevant to the surgical patient and their associated pre and post operative environment that is compassionate, appropriate and effective. This care will adequately assess, treat and follow up the surgical patient and will promote their future health, as well. Objective 1: The Surgery resident will demonstrate that they are capable of providing effective family medicine oriented surgical care. They will be able to demonstrate an effective pre-operative assessment, effective operating room skills, compassionate perioperative care, hospital rounding skills and also appropriate post-operative instructional care and follow-up office care. These items will be measured by the surgery attendings using direct observation and 360 degree service evaluations. Hospital patient satisfaction surveys will also be utilized. Further utilization of these acquired patient care skills will be done in the family medicine setting as the resident progresses over time and will be further assessed and measured by the family medicine attending faculty using the same methods. Objective 2: Patient presentation to attending physicians on daily rounds will be an integral part of the patient care learning experience. The resident will become proficient and efficient in presenting a complete and well thought out presentation and plan of care to the attending surgical doctor they are assigned to. Measurement will be by daily direct observation and feedback and also rotational evaluations. Objective 3: Surgery II specific objectives: The resident rotating on the second surgery month will be expected to have an advanced ability and knowledge base that is built upon what he/she has learned in Surgery I. The caseload during this month is typically more acute and the resident’s previous experience will be utilized to further enhance their learning and abilities in the more complex, surgical ICU patient. The resident will be expected to play a vital team role and participate in rounding, advanced surgical cases and the learning of various specialized surgical procedures. The resident will also function with a higher level of independence commensurate with his or her ability. Medical Knowledge Goal Residents will demonstrate knowledge of established biomedical, clinical, epidemiological and social-behavioral sciences—as well as the application of this knowledge--in caring for the general surgical patient. Objective 1: At the beginning of the first month of Surgery the resident will complete the pre-tests as assigned in Surgery for the medical knowledge curriculum. This will be done utilizing the Surgically-related AAFP monographs that have been designated for use in this rotation as well as the residency designed pre-test. 100% mastery will be expected. These tests will be turned in to the residency secretaries, graded and kept in the resident’s record. Objective 2: The resident will read about, stay current in and demonstrate surgical knowledge and skills utilizing up to date surgical textbooks and other online sources, in both the Altoona Family Physicians library and the libraries of the surgeon and the hospital. Effective observation and monitoring of this learning activity will be by both direct observation and performance on the tests in Objective 1. Objective 3: The resident will attend Surgical-related lectures as scheduled in the didactic conference schedule. These will include general surgery lectures, trauma service lectures and various specialty surgical lectures. Measurement of lecture-obtained knowledge will be by recorded attendance, observed participation and future observation of the application of the knowledge to clinical situations. Objective 4: Surgery II specific objectives: Obtaining an advanced and more confident surgical knowledge base. Further reading and studying of in-depth materials as they relate to taking care of the more advanced and acute ICU surgical patient. Exposure to more difficult and acutely ill surgical patients. Training and experience in surgical wound care at the ARHS Wound Clinic. Application of more of the knowledge and skills learned in the required ATLS course and surgical procedural workshop from the first year. Completion of the written post-tests for Surgery will be done at the conclusion of the second month of Surgery. Objective 5: The resident will acquire and demonstrate the following listed, AAFP endorsed Attitudes, Knowledge and Skills as they relate to the surgical patient in the family medicine context. These will be assessed and measured both globally and specifically by a combination of direct observation, surgical rounding participation, pre and post test achievement, 360 evaluations and various survey methods: Attitudes The resident should develop attitudes that encompass: 1-Recognition of the importance of collaboration between the family physician and the surgeon as partners in the evaluation of surgical patients and the decision-making process regarding their care. 2-An awareness of the principles involved in differentiating the causative origin of clinical symptoms that result in the need for medical and/or surgical intervention. 3-Sensitivity to concerns and anxieties of the patient and the patient’s family members regarding the potential for surgical intervention. Knowledge In the appropriate setting, the resident should demonstrate the ability to apply knowledge of: 1. Basic principles of surgical diagnosis a. Basic surgical anatomy b. Wound physiology, care and healing processes c. Clinical assessment, including history, physical examination, laboratory evaluation, and differential diagnosis of key signs and symptoms of surgical conditions d. Invasive versus noninvasive diagnostic tests 2. Anesthesia a. Premedication b. Agents and routes of administration c. Resuscitation methods 3. Recognition of surgical emergencies 4. Ethical, legal and socioeconomic considerations a. Informed consent b. Quality of life c. Cultural sensitivity d. End-of-life issues 5. Preoperative assessment a. Recognition of appropriate surgical candidates b. Surgical risk assessment c. Comorbid diseases d. Antibiotic prophylaxis e. Patient preparation (bowel, medication, schedule, etc.) 6. Intraoperative care a. Basic principles of asepsis and sterile technique b. Patient monitoring c. Fluid management d. Blood requirements e. Temperature control f. Use of basic surgical instruments 7. Postoperative care a. Routine i. Wound care ii. Patient mobilization iii. Nutrition management iv. Pain management v. Suctions and drains b. Common complications i. Fever work-up and management ii. Wound dehiscence iii. Urinary retention iv. Hemorrhage v. Pneumonia vi. Atelectasis vii. Fluid overload viii. Transfusion reaction ix. Thrombophlebitis x. Pulmonary embolism xi. Oliguria xii. Respiratory insufficiency xiii. Ileus xiv.Infection xv. Shock 8. Outpatient surgery a. Patient selection b. Conscious sedation c. Postoperative observation principles d. Follow-up care 9. Office care of common conditions a. Lumps, bumps and abscesses b. Simple lacerations c. Superficial burns d. Common methods of anesthesia 10. Adjunctive and long-term care of organ donors and recipients 11. Adjunctive and long-term care of bariatric surgical patients 12. Recognition and care of surgical wounds a. Penetrating wounds b. Avulsion, crush or shear injury wounds c. Bite wounds
Skills
In the appropriate surgical or family medicine setting, the resident should demonstrate the ability to independently perform or appropriately refer: 1. Preoperative assessment 2. Surgical risk evaluation, including assessment of medication use a. Surgical risk evaluation b. Physical assessment c. Radiographic assessment d. Noninvasive diagnostic procedures e. Invasive diagnostic procedures i. Paracentesis ii. Nasogastric lavage iii. Peritoneal lavage iv. Thoracentesis v. Bladder aspiration vi. Central venous access (central venous pressure, Swan-Ganz catheter) vii. Venous cutdown viii. Arterial puncture and catheterization ix. Needle aspiration and biopsy technique 3. Recognition of need for emergent surgical techniques a. Cricothyroidotomy b. Needle thoracostomy c. Pericardiocentesis 4. Intraoperative skills a. Preparation and draping of operative field b. First assist at major surgery c. Basic use of surgical instruments d. Incision and dissection e. Exposure and retraction f. Hemostasis g. Estimation of blood loss h. Fluid replacement i. Wound closure i. Technique selection (ligature, staples, adhesives) ii. Suture selection iii. Drains iv. Dressings 5. Postoperative care a. Suture removal b. Dressing changes c. Drain removal 6. Minor surgical techniques a. Local anesthesia b. Simple excision c. Incision and drainage of cysts and abscesses d. Aspiration e. Ear piercing f. Foreign body removal g. Minor burns h. Vasectomy i. Cauterization and electrodesiccation j. Punch biopsy k. Wound debridement l. Enucleation and excision of external thrombotic hemorrhoid m. Nail surgery n. Cryosurgery (liquid nitrogen) 7. Counseling about advance directives, organ donations and end-of-life issues 8. Recognition and treatment of venous stasis ulcers, arterial ulcers and neuropathic ulcers 9. Grading and treatment of decubitus ulcers Practice Based Learning and Improvement Goal Residents will demonstrate the ability to investigate and evaluate their care of surgical patients, to appraise and assimilate surgical scientific evidence, and to continuously improve surgical patient care based on constant self evaluation and lifelong learning. Objective 1: The resident will initially identify his/her strengths, deficiencies and limits in their surgical knowledge, expertise and application abilities. Initially this will be evaluated by pre-testing and also by initial evaluated performance during the first days of the rotational experience. Reading, studying, skill practice and attending guidance will be the mainstays of ongoing improvement through the rotation. Post rotational testing along with attending feedback and evaluation will further evaluate and shape the surgical learning experience. Objective 2: The resident will set performance, learning and improvement goals for their surgery experience based on information obtained in objective one. These should be written, discussed with the attending and checked off when achieved. References, hands-on learning practice sessions and actual inpatient and outpatient surgery sessions will be the venues for achieving these goals. Objective 3: The resident will be an active participant in the surgical education of patients, their families, other residents, other healthcare personnel and also any medical students or other learners they may encounter. The resident’s abilities in education will be monitored for improvement by the attending physician and this will be reflected in and be a part of the rotational evaluation as well as daily formative oral feedback. Objective 4: Surgery II specific objectives: During the Surgery II month special emphasis will be placed on developing and utilizing the practice based learning skills acquired in the first year surgical rotation. The re-identification of surgical skills and surgical knowledge strengths and abilities will be done at the onset of the rotation, in conjunction with the assigned attending surgeon. Every attempt will then be made to increase and add to those strengths and abilities and take them to the next level in dealing with the more advanced surgical patient. Advanced reading and study materials will be utilized to help achieve this, along with internet based learning resources. Measurement will be in the form of direct daily feedback, written evaluations and the surgical post tests. Systems Based Practice Goal Residents will demonstrate an awareness and responsiveness to the larger system and context of healthcare, as it relates to surgery, as well as the ability to call effectively on the resources of that system in order to provide optimal surgical healthcare. Objective 1: The resident will be able to effectively coordinate surgical patient care within both the local and regional healthcare system. This will involve utilizing highly effective communication and presentations skills regarding clinical cases, having a knowledge and understanding of both the both the local and regional surgical services available, and knowing when and how to effectively transfer the care of surgical patients. This will be measured by direct observation, 360 evaluations and also by formative feedback. Objective 2: The resident will be able to work effectively to advocate for surgical patients in multiple surgical healthcare delivery setting venues, including the family medicine office, the emergency room and the surgical office—among others. The resident will take the surgical skills learned and apply them in the traditional surgical setting and also in the other noted venues. The resident will be able to effectively access appropriate surgical care, when needed, from any of these. Formative feedback, rotational evaluations and post testing will help to measure this objective. Objective 3: Surgery II specific objectives: During Surgery II the information, learning objectives and skills acquired that are outlined above will be developed and enhanced. An advanced level of understanding of the larger healthcare system will be realized. The ability to negotiate and effectively communicate within that system will be improved with further experience and individual patient encounters. Professionalism Goal Residents will demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles in the surgical care setting. Objective 1: Residents will at all times maintain a professional demeanor and decorum. They will be prompt and will appear professional in both their attire and attitude. They will treat all surgical patients with compassion, integrity and respect. They will demonstrate a responsiveness to the needs of the surgical patient that recognizes severity of illness, comfort and acuity. These professional attributes will be assessed by direct observation and feedback by the attending on daily rounds and summarized on the rotational evaluation. In the family medicine setting they will also be assessed using videotaping and program director observation. Objective 2: Residents will demonstrate, in the surgical care setting, a respect for patient privacy and autonomy. In the administration of surgical care, the importance of privacy is paramount. The resident will develop and use patient care skills that recognize this and show concern for privacy, both in an informational and a physical sense. As well, recognizing patient autonomy in the surgical setting is often challenging. The resident will be aware of and utilize current legal, informed consent and other principles consistent with the patient’s best interest and desires, allowing them to make their own informed, best decisions. The will be measured by testing, direct observation, patient surveys and also evaluated in rotational evaluations. Objective 3: Surgery II specific objectives: Professionalism is an attribute that develops and grows with learning and increased experience. As such, the natural result is that the many aspects of being a professional physician that have been outlined above will be expected to enhance and improve with time. The increased level of patient exposure and increased autonomy that is afforded during the second month of surgery will allow the resident family physician to grow and develop in this area. Measurement will continue to be via utilization of the direct observation, multiple written evaluation and formative feedback methods. Interpersonal and Communication Skills Goal The resident will demonstrate effective interpersonal and communication skills that result in the effective exchange of information and teaming of patients, their families and professional associates—in the surgical care setting. Objective 1: The resident will develop and display skills commensurate with acting in consultative role to other physicians and health professionals. The surgical specialty role is one that is especially amenable to learning and mastering this consultative role. The resident, under the watchful and guiding eye of the surgical attending physician, will act as the initial surgical consultant in many cases during this rotation. Formative immediate feedback will be given by the attending. Additional feedback will be given on review of consultative notes. Rotational summary evaluations will also assess this vital learned skill. In addition, this learned consultative skill is also used and evaluated on the medical service--doing medical consults. Objective 2: The resident will write, dictate, proofread and sign comprehensive, timely and legible medical records. Nowhere are quality and timely medical records more important than on the surgical service. Operative notes and dictations will be initially instructed, done by the resident and evaluated by the service attending doctor on both a temporal and longitudinal basis with direct observation and feedback. The overall quality of records will be evaluated in the end of service written evaluation. Timeliness of record completion will be monitored by the attending and also the Health Information Department of the hospital. An overall assessment of resident record completions skills is also done in the resident’s yearly global evaluation. Objective 3: Surgery II specific objectives: The resident will demonstrate that he/she has achieved an advanced level of ability as it relates to communication skills. Performance of all required notes, consultations, dictations and records will be done much more independently and with a higher level of expected quality. Communication with other health care providers and professionals will be performed more independently as a caring and integral member of the surgical team. Daily guidance, oversight and feedback will continue to be given by the attending on service. Surgery I and II Information Sheet First Day Instructions Surgery I: See HCFA for your exact schedule. First day of Surgery I go to the Anesthesia Department in the OR. First day with the surgeon at the Altoona campus—call or page your assigned surgeon to arrange a meeting time and place. Contacts—Surgery I: Dr. Magee-946-0891, Dr. Newlin-943-7040, Anesthesia—Dr. Falcone or Diane Andersen- Ext. 7811 or 2103, Flo Eberhart (procedures) 935-2042. Paging operator number is 889-2177. Residency contacts: Julie Fochler, Dr. Art Morrow---both extension 2020 First Day Instructions Surgery II See HCFA for your exact schedule. First day of Surgery II go to Wound Clinic at the Bon Secours campus. First day with the surgeon at the Altoona campus—call or page your assigned surgeon arrange a meeting time and place. Contacts—Surgery II: Drs. Lampard/Siddiqui-943-7040, Wound Clinic-Ellen Schraff, RN—Ext. 2793 Paging operator number is 889-2177. Residency contacts: Julie Fochler, Dr. Art Morrow—both extension 2020
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