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GENERAL OBJECTIVES FOR SURGICAL INTERNS
 
General Surgery Objectives for All PGY I Service Rotations  
The resident learner is expected to have accomplished the following General Surgery learning objectives by completion of the PGY I training year.

**The General Surgery objectives apply to completion of ALL PGY I rotations (General Surgery, Vascular Surgery, Trauma Surgery-Critical Care-Transplantation).

**A specific service’s objectives are labeled “Rotation” knowledge and skills.


Knowledge Objectives for All PGY I Rotations
Skills Objectives for All PGY I Rotations
Objectives in Professionalism for All PGY I Rotations


 

Knowledge Objectives for All PGY I Rotations
Fever, Microbiology, and Surgical Infection

  • Know the mediators of fever, differential diagnosis, evaluation and management of the febrile patient in order to initiate appropriate workup of fever and provide supportive treatment
  • Know the common flora of various organ systems and the manifestations of infection of these organ systems
  • Know the proper use of prophylactic antibiotics
  • Know the classification of wounds (clean, clean-contaminated, contaminated, infected)
  • Understand the development of bacterial resistance and the basic characteristics of epidemics.

Epidemiology and Public Health

  • Be knowledgeable in AIDS diagnosis and prevention of HIV infection
  • Know the common opportunistic infections of AIDS and other immunocompromised patients, their clinical manifestations, diagnosis, and treatment
  • Understand the epidemiology and treatment of sexually transmitted diseases and other communicable diseases

Nutrition

  • Know nutritional requirements under normal conditions
  • Be familiar with intraoperative monitoring
  • Know the dose range and complications of the following agents: barbiturates, local anesthetics, paralyzing agents, reversing agents
  • Know when and how to use epinephrine, hyaluronidase, in local anesthesia
  • Know the pharmacology of cardiovascular, antihypertensive, NSAID, and other common drugs
  • Know the implications of hepatic or renal insufficiency on the use of various drugs
  • Be aware of common drug interactions and toxicity
  • Know the complications and effects of NSAID treatment, and the use of these drugs in the surgical patient
  • Know the forms of steroid drugs, doses, indications, and complications of steroid therapy relevant to the surgical patient
  • Know the normal function and normal range of test values for the major endocrine organs (thyroid, parathyroid, adrenal cortex and medulla, pancreatic islets, pituitary, gonads)
  • Know the pathophysiology, supportive care, and surgical indications in a patient with bowel obstruction
  • Know the surgical anatomy and applied physiology of the major endocrine organs
  • Recognize endocrine diseases of hypo- and hyper- function

Pharmacology and Pharmacokinetics

  • Know the pharmacology of cardiovascular, antihypertensive, NSAID, and other common drugs.
  • Know the implications of hepatic or renal insufficiency on the use of various drugs
  • Be aware of common drug interactions and toxicity
  • Know the complications and effects of NSAID treatment and the use of these drugs in the surgical patient
  • Know the forms of steroid drugs, doses, indications, and complications of steroid therapy relevant to the surgical patient

Organ-Specific Areas

  • Demonstrate an understanding of the anatomy, physiology, pathophysiology, and presentation of diseases of the abdominal cavity and pelvis
  • Describe changes in these organ systems that result from the aging process: heart, lung, kidney, brain, hematopoetic system
  • Explain absorption and secretory functions of the peritoneal surfaces and the diaphragm
  • Describe the anatomy of the omentum and its role in responding to inflammatory processes
  • Assess the following signs associated with the acute abdomen and describe their pathophysiology: referred pain, rebound tenderness, guarding, rigidity
  • Specify characteristics of the history, physical examination findings, and mechanism of visceral and somatic pain for these processes: acute appendicitis, bowel obstruction, perforated ulcer, ureteral colic, diffuse peritonitis
  • Know the pathophysiology of the development of acute renal failure; the differentiation of prerenal, renal, obstructive types of renal failure; and the general concepts of prevention and treatment of ARF
  • Know the manifestations—clinical and by laboratory testing—of obstructive pulmonary disease and pulmonary insufficiency, and their surgical perioperative management
  • Recognize bronchoconstrictive disorders and their perioperative management
  • Understand the implications of anemia for oxygen delivery
  • Understand the pathophysiology of acid aspiration, recognize patients at risk, and know the general methods of prevention of aspiration
  • Recognize the clinical and radiologic features of bowel obstruction and its major causes
  • Know the normal function and normal range of test values for the major endocrine organs (thyroid, parathyroid, adrenal cortex and medulla, pancreatic islets, pituitary, gonads)
  • Apply knowledge of embryology to understand the common congenital anomalies
  • Know the surgical anatomy and applied physiology of the major endocrine organs
  • Recognize endocrine diseases of hypo- and hyper- function
  • Know the rules of inheritance and the importance of dominant and recessive genes and gene expression
  • Know the mechanism of gallstone formation
  • Know the basic anatomy and physiology of the endocrine and exocrine pancreas
  • Recognize the clinical manifestations of acute and chronic pancreatitis
  • Eye: Know the major manifestations and basic treatment of glaucoma, ocular injury and infection
  • Recognize hereditary diseases and syndromes, such as MEN, Gardner, BrCA
  • Have a basic understanding of the application of molecular genetics to diagnosis and therapy of surgical diseases
  • Know the pathophysiology of common GI diseases such as diarrhea, inflammatory bowel disease, peptic ulcer disease, pancreatic exocrine deficiency, delayed gastric emptying, reflux
  • Recognize the basic gross and microscopic findings of surgical diseases and their implications
  • Understand the implications of positive margins and the limitations of frozen section and biopsy techniques
  • Describe the characteristics of the immune response in terms of cell and antibody-mediated immunity, specificity, primary and secondary (anamnestic)
  • Recognize the implications of immunodeficiency and immunosuppression
  • Understand the basic principles of tumor biology and carcinogenesis
  • Understand and apply the TNM classification for tumors
  • Know the general applications for radiation therapy and the mechanisms of radiation effect, acute and chronic
  • Understand the basic mechanisms of metastasis
  • Know regional lymph node anatomy and the principles of a cancer operation
  • Understand the acute and chronic complications of radiation therapy
  • Know the surgical implications of pregnancy in evaluation of acute presentations such as abdominal pain
  • Have a general appreciation of the prevalence of substance abuse in health professionals, its recognition, and approach to treatment
  • Know the acute presentations of intoxication and its complications, and the acute management of the intoxicated patient
  • Know the indications for drug testing and the samples needed
  • Know the surgical implications of substance abuse
  • Know the various imaging techniques available in investigations of cerebrovascular diseases, and their general indications and interpretation
  • Know the indications, medical applications, and complications of lasers in surgical procedures


 


Skills Objectives for All PGY I Rotations

Patient Evaluation, Assessment, and Management

  • Demonstrate the ability to formulate and implement a diagnostic and treatment plan for diseases of the abdomen and pelvis that are amenable to surgical intervention
  • Obtain a detailed surgical history and obtain and review relevant medical records and reports
  • Perform a detailed physical examination, including as appropriate: proctosigmoidoscopy, flexible sigmoidoscopy, hand-held Doppler
  • Develop a complete differential diagnosis
  • Maintain a personal patient log
  • Write a succinct H&P, including a risk assessment evaluation
  • Obtain a written informed consent
  • Document the treatment plan in the medical record, including the indications for treatment
  • Dictate an operative note and discharge summary

Assessment of Basic Diagnostic Tests and X-Rays

  • Order and interpret basic laboratory tests and screening X-rays, and evaluate the patient’s cardiac, pulmonary, renal, and neurologic status
  • Develop a preoperative assessment of risk factors

Airway Management and Anesthesia

  • Obtain oropharyngeal control of the airway and provide Ambu ventilation
  • Perform orotracheal intubation, nasotracheal intubation, tracheostomy, cricothyroidotomy
  • Interpret the anesthesia record
  • Write preanesthetic orders
  • Position the patient properly for operative exposure, temperature control, and protection from pressure/traction
  • Under supervision: administer a local block, administer a spinal anesthetic, administer general anesthesia
  • Understand and use conscious sedation
  • Be ACLS certified
  • Review, prioritize, and order medications the patient is currently taking, as appropriate
  • Use and understand the nursing notes and patient data
  • Prescribe activity level, management of medications, pain management, follow up appointments, and obtain urgent contact information
  • Recognize abnormalities in basic radiologic and laboratory tests and learn normal values and ranges
  • Choose the optimal imaging technique
  • Interpret basic EKG findings
  • Recognize ischemia and arrhythmia patterns on EKG
  • Use proper techniques for skin preparation and draping incision site
  • Perform minor surgical procedures, including minor excisions, skin suture using simple, subcutaneous, mattress sutures or staples
  • Perform simple wound debridement with supervision and perform sterile and contaminated dressing changes

Surgical Skills

  • Perform as first assistant. Obtain hemostasis of small vessels and exposure of operative field
  • Perform basic maneuvers (e.g., suture of skin, soft tissues, fascia; tie knots; obtain simple hemostasis)
  • Learn basic techniques of dissection and handling of tissues
  • Under supervision, complete the following:
    • Excise benign lesions of skin and subcutaneous tissues
    • Perform lymph node biopsy
    • Remove superficial foreign bodies
    • Incise and drain abscesses
    • Repair simple lacerations
    • Repair umbilical and type I and II groin hernias
    • Perform appendectomy
  • Understand indications for and utilize appropriate methods of routine and reverse isolation procedures
  • Maintain appropriate sterile technique in the ER, at the bedside, in the ICU, and in the office
  • Differentiate between wound infection, hematoma, and seroma, and initiate therapy
  • Perform extensive debridement with supervision
  • Debride and pack wounds and apply dressings
  • Recognize and differentiate between wound infection and necrotizing fasciitis, and detect crepitus
  • Identify wound dehiscence and evisceration

Fever, Microbiology, and Surgical Infection

  • Initiate definitive treatment with appropriate antibiotics. Be able to monitor antibiotic levels and recognize drug-related complications. Know the antibiotic of choice.
  • Know and apply the principles of prevention of nosocomial infections, sterile technique and universal precautions
  • Order and interpret the appropriate imaging studies for localization of an infected focus.
  • Know and apply the principles of incision and drainage.
  • Recognize the septic syndrome and initiate appropriate supportive treatment. Be familiar with current literature concerning the causes and mediators of sepsis syndrome and its pathophysiology

Nutrition

  • Assess nutritional status using observation and basic laboratory values
  • Calculate routine protein-calorie requirements
  • Perform a metabolic assessment of the surgical patient
  • Calculate and order basic enteral or parenteral formulas
  • Manage central IV lines
  • Insert and manage gastrostomy or jejunostomy feeding tubes
  • Assess when a postoperative patient can be fed and assess adequacy of intake
  • Know and utilize comparative costs of nutritional support methods.
  • Complete, document, and assess appropriate workup, write preoperative orders, and obtain required consultation from other specialists

Prioritize and Manage Complications

  • Assess and manage complications or change in health status such as: altered mental status, fever, hypotension, hypovolemia, oliguria, hypoxia, pain, vomiting, distention, nausea, gastrointestinal bleeding, bleeding at bedside, other bleeding and coagulopathy, atelectasis, pneumonia, aspiration, fecal impaction, constipation, chest pain, dyspnea, pneumothorax, congestive heart failure, pulmonary edema, superficial phlebitis, deep venous thrombosis, pulmonary embolus, urinary retention, diabetic ketoacidosis or hyperosmolar coma, peripheral ischemia or cyanosis, seizures, alcohol or drug withdrawal

Technical Skills

  • Perform and interpret paracentesis and diagnostic peritoneal lavage
  • Perform arthrocentesis
  • Insert, maintain, and remove chest tubes
  • Perform difficult male catheterizations or a suprapubic stick
  • Manage tubes and drains placed operatively or percutaneously
  • Immobilize extremities, cast simple fractures
  • Know and apply specific recommendations for tetanus immunization, active and passive
  • Know the clinical manifestations of rabies in carrier and patient, and agents available to prevent development of disease
  • Obtain proper wound specimen and perform and interpret Gram stain
  • Insert and maintain nasogastric tubes and urethral catheters
  • Perform a lumbar puncture
  • Assess and manage complications or change in health status
  • Perform and interpret paracentesis and diagnostic peritoneal lavage
  • Perform arthrocentesis
  • Insert, maintain, and remove chest tubes
  • Diagnose and manage acute deep venous thrombosis
  • Acutely manage a patient with a suspected acute pulmonary embolus, and provide a differential diagnosis
  • Apply effective preventive measures for DVT and PE
  • Manage chronic deep venous insufficiency
  • Interpret drug levels and utilize pharmacokinetics for drug administration
  • Determine the physical findings and differential diagnosis in a patient with abdominal pain
  • Develop a differential diagnosis through history and physical examination, order and interpret appropriate imaging and biochemical studies, and make a diagnosis of peritonitis
  • Understand the physiology of peritonitis and apply it to the general management of a patient. Recognize the need for surgical intervention
  • Recognize the clinical manifestations of non-surgical conditions such as PID and acute pancreatitis and differentiate from peritonitis requiring operation
  • Recognize and initiate treatment for an acute anaphylactic reaction
  • Establish the cause of anemia in a patient and initiate therapy
  • Understand the implications of anemia for oxygen delivery
  • Know and apply acute treatment for a patient who has aspirated
  • Manage a diabetic patient perioperatively, acutely, and chronically
  • Recognize and treat hypoglycemia, and prevent its occurrence
  • Manage the perioperative care of a patient with hyperthyroidism
  • Recognize and treat postoperative hypocalcemia

Coagulation and Anticoagulation

  • Choose the appropriate tests for diagnosis of a coagulopathy, and have a working knowledge of factor analysis
  • Initiate and monitor therapeutic anticoagulation and its complications

Pharmacology and Pharmacokinetics

  • Interpret drug levels and utilize pharmacokinetics for drug administration

Organ-Specific Areas

  • Recognize rhythm disturbances, myocardial ischemia on EKG.
  • Know and apply appropriate treatment for supraventricular tachycardia
  • Treat congestive failure and acute pulmonary edema
  • Manage urinary tract infections
  • Understand and apply the principles of bladder management
  • Know the principles of bladder cystometry and interpret cystometric data
  • Know the types and differential diagnosis of anemia, and the proper choice of diagnostic tests

Acute Abdomen and Peritonitis

  • Develop a differential diagnosis through history and physical examination, order and interpret appropriate imaging and biochemical studies, and make a diagnosis of peritonitis
  • Recognize the clinical manifestations of non-surgical conditions such as PID and acute pancreatitis and differentiate from peritonitis requiring operation
  • Know the pathophysiology, supportive care, and surgical indications in a patient with bowel obstruction
  • Manage a diabetic patient postoperatively, acutely, and chronically
  • Recognize and treat hypoglycemia, and prevent its occurrence
  • Evaluate and acutely manage the diabetic foot. Counsel diabetic patients on foot care
  • Eye: Manage a patient with glaucoma in the perioperative period
  • Eye: Recognize the fundus findings of SBE, TIA, diabetes, tumor, hypertension, CMV
  • Emergency management of ocular emergencies such as: acute glaucoma, ruptured or lacerated globe, retinal detachment, corneal ulcer, orbital hemorrhage, signs of intracranial aneurysm
  • Diagnose and acutely manage a patient with: ileus and bowel obstruction, inflammatory bowel disease, GI bleeding, volvulus, diarrhea, appendicitis, pancreatitis
  • Become proficient at core and fine-needle aspiration biopsy of palpable lesions
  • Manage hypertension in a surgical patient. Understand multidrug therapy and the toxic and side effects of antihypertensive drugs
  • Apply and interpret appropriate tests for the laboratory evaluation of immune function. Recognize an immunocompromised state
  • Understand the mechanisms of acute transplant rejection and recognize its presentation. Be familiar with immunosuppressive therapy
  • Do an appropriate metastatic workup of a patient with malignancy
  • Manage a pregnant patient perioperatively
  • Recognize the surgical patient with mental status or physiologic changes compatible with substance abuse and develop a differential diagnosis
  • Differentiate between stroke, TIA, and non-cerebrovascular events causing neurological symptoms
  • Become capable of using electrocautery safely
  • Become trained in basic laser use


 


Objectives in Professionalism for All PGY I Rotations
PGY I: Professionalism
Discharge Planning

  • Utilize the institutional resources such as social services, homehealth care, outpatient department for effective discharge planning. Be able to begin this process well in advance for efficient and patient-oriented discharge

Medical Economics

  • Appreciate the need for cost-benefit analysis of workup and treatment options, and participate in the development of a cost-effective patient management plan
  • Understand the documentation needed for coding and billing

Medical Jurisprudence

  • Understand the concept of risk management and the needed documentation in the medical record
  • Understand the essential nature of the informed consent and be able to obtain informed consent from patients.

Quality Improvement and Outcomes Assessment

  • Understand the methods of outcomes assessment, including measures of health status and patient satisfaction
  • Be aware of the principles of continuous quality improvement and cooperate with the CQI process

Rehabilitation

  • Understand the role of rehabilitation services for disabled patients
  • Have specific information about accessing rehabilitation services, indications for referral, and the potential benefits to be anticipated

Biostatistics and the Scientific Method

  • Understand the principles of clinical research and clinical trials, and be able to perform basic statistical analysis of data
  • Develop critical reading skills
  • Understand the application of biostatistics to data
  • Understand the principles of clinical research

Medical Informatics and Communications Skills

  • Have basic computer skills and use on-line medical applications
  • Discuss pertinent aspects of a patient’s condition with a consultant
  • Present a topic with a pertinent review of the literature at a conference
  • Maintain a personal library and reference system
  • Utilize SESAP for self-study and assessment
  • Be proficient with word-processing programs, spreadsheets, simple databases
  • Know how to access library resources related to a patient problem and complete a literature search using Medline or Grateful Med
  • Be able to utilize on-line services (Internet, www)
  • Become familiar with slide-making software

Professional Behavior and Attitude, Medical Ethics

  • Respect all patients as individuals, and their privacy and modesty
  • Use discretion in private and public conversations
  • Maintain honesty, an inquiring mind, and a lifelong learning habit
  • Become aware of one’s own limitations and accept criticism
  • Become a lifelong learner by developing self-directed learning skills
  • Know the resources available when ethical or professional behavior problems arise (department, institution, ACS)
  • Develop skills n patient and family communication and the doctor-patient relationship. Develop psychosocial acceptance
  • Understand the essential nature of collegiality and develop interpersonal skills with other health professionals
  • Behave in a professional manner, develop a strong work ethic, be responsive to patients and co-workers, and work as a member of the team
  • Become aware of one’s limitations and accept criticisms
  • Develop skills in translating knowledge to patient management
  • Begin mentoring and role-model patterns
  • Develop teaching skills and facilitate medical student learning
  • Appreciate and utilize cost-benefit analysis
  • Be aware of a patient’s Advanced Directives and conform, if possible, to their wishes. Preserve the patient’s autonomy. Respect the aged.
  • Accept responsibility and demonstrate reliability and dependability
  • Become well organized and efficient, and develop skills to estimate the time to accomplish a task
  • Be familiar with the principles of total quality management and cooperate with utilization review