RUHS/UCR FM Residency Program 2016

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Abel Fletcher
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1 General Surgery Goals and Objectives PGY 1 Rotation Description PGY -1 residents will develop the skills to manage common surgical related conditions seen in primary care. In addition, residents will be exposed to patients requiring surgical intervention in the outpatient and inpatient setting and learn different treatment modalities as they pertain to specific surgical situations. During this rotation, residents will gain the knowledge to evaluate, diagnose and manage common surgical conditions seen in all patients. Each PGY 1 resident will complete 1 block rotation in General Surgery. Residents are required to abide by the General Surgery expectations and guidelines, which will be provided during orientation. Goals and Objectives: Patient Care 1. Cares for acutely ill patients presenting with surgical issues in urgent and emergent situations in all settings a. Gathers essential information about the patient (history, exam, and diagnostic testing) b. Generates differential diagnosis for common conditions c. Accurately documents a clinical encounter on a patient with surgical conditions d. Develops a management plan that includes appropriate clinical guidelines e. Recognizes role of clinical protocols and guidelines in acute situations that impact the patient f. Consistently recognizes common situations that require urgent or emergent medical care and utilizes appropriate consultation. g. Stabilizes the acutely ill patient utilizing the appropriate clinical protocols and guidelines. 2. Cares for patients in the perioperative period. a. Obtain complete histories, interpret vital signs, perform appropriate physical examinations, and effectively present these findings to a surgeon. a. Assessment of operative risk, including management of peri-operative nutrition, fluids, and electrolytes b. Obtains lab tests appropriate for patients condition c. Develops appropriate diagnostic and therapeutic management plans for acute conditions in surgical patients. 3. Partners with patients, families, and community to improve health through disease prevention and health promotion a. Arranges a multidisciplinary approach and coordinates patient care with the health care team b. Understand the psychosocial impact of surgery on the patient and family. 4. Acquire the skills to perform basic suturing techniques. 5. Acquire the skills to assist in common procedures under supervision of a surgeon, which include: sterile technique, including OR etiquette, basic surgical assisting, basic knot tying/advantages of suture types, Laceration repairs, Incision and Drainage, laparoscopic procedures, appendectomy, cholecystectomy, hernia repairs, bowel resections, peritoneal lavage, principles of drain management, resuscitation of a trauma patient, wound care, limb amputations, excisional biopsy procedures, and surgical exploration of the abdomen.

2 Medical Knowledge 1. Has sufficient medical knowledge to provide care to the patient with surgical conditions as a FM resident. a. Knows appropriate patient education for the different surgical situations preop care and postop care b. Uses the American Board of Family Medicine (ABFM) In- Training Assessment resident scaled score to further guide his or her education c. Demonstrates capacity to assess and act on personal learning needs d. Knows safe prescribing practices used in surgery 2. Applies critical thinking skills in the care of patients a. Demonstrates basic decision making capabilities b. Appropriately uses, performs and intreprets diagnostic tests and procedures c. Synthesizes information from multiple resources to make clinical decisions a. Understands the differential diagnosis, diagnostic approach (including history, exam, lab and imaging assessments, and clinical reasoning) and management of patients with common surgical conditions including, but not limited to: cholelithiasis; cholecystitis; pancreatitis; appendicitis; diverticulitis; groin and ventral hernias, including incarceration and strangulation; hemorrhoids; perirectal abscess/fistula; fibroadenoma and other benign breast lesions; breast cancer; colon cancer; bowel obstruction; surgery for complications of peptic ulcer disease and ischemic bowel Interpersonal and Communication Skills 1. Develops meaningful, therapeutic relationships with patients and families a. Creates a non-judgemental and safe environment for patients b. Respects patients autonomy in their health care decisions 2. Demonstrates effective communication with patients, families, and the healthcare team a. Participates in family meeting to discuss patient s condition and treatment plan b. Engages patients perspective in shared decision making 3. Effectively communicates and works collaboratively with all staff including resident physicians, attending physicians, specialists and hospital personnel in a way that fosters mutual respect and effective patient care. a. Maintain accurate medical records regarding patient encounters including procedures and consults. b. Demonstrates consultative exchange that includes clear expectations and appropriate information c. Presents and documents patient data in a clear, concise and organized manner. Practice-Based Learning and Improvement 1. Locates, appraises and assimilates evidence from scientific studies related to the patients health problems a. Utilizes the best evidence in caring for patients with or at risk for various surgical conditions. b. Critically evaluates information from others, including colleagues, experts, pharmacists, patients c. Formulates a searchable question from a clinical scenario d. Learns how to critically evaluate literature about current surgical care. 2. Demonstrates self-directed learning a. Uses information technology to manage and retrieve information about surgical cases and supports own education. b. Uses feedback to improve learning and performance c. Applies medical knowledge learned in the OR, surgical ward, surgery clinic and own continuity patients and disseminate the learned information to others to facilitate learning. d. Acknowledges gaps in personal knowledge and expertise and frequently asks for feedback

3 3. Improves systems in which the physician provides care a. Able to implement changes in patient care based on new information obtained from attending rounds, clinical experience, review of the literature, office experience and other sources. b. Recognizes inefficiencies, inequities, variation and quality gaps in health care delivery c. Compares care provided by self and practice to external standards and identifies areas for improvement. Professionalism 1. Completes a process of professionalization a. Demonstrates a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity when dealing with patients. b. Dress appropriately and maintain good personal hygiene in accordance with hospital policy c. Recognizes that conflicting personal and professional values exist d. Demonstrates honesty, integrity and respect to the patient, family and team members 2. Maintains emotional, physical, and mental health; and pursues continual personal and professional growth a. Maintain patient privacy adhering to standards set forth by HIPAA. b. Recognizes fatigue, sleep deprivation and impairment c. Accepts constructive feedback 3. Demonstrates professional conduct, accountability and good work habits a. Recognizes the importance of timeliness, efficiency, and punctuality. b. Presents themselves in a professional and respectful manner c. Attends to responsibilities and completes duties as required d. Maintains patient confidentiality 4. Demonstrates humanism and cultural proficiency a. Recognizes impact of culture on health and health behaviors b. Consistently demonstrates compassion, respect and empathy. c. Shows sensitivity and responsiveness to patients and families culture, race, gender, sexual orientation, age, socioeconomic status and physical or mental disabilities. Systems-Based Practice 1. Emphasizes patient safety for surgical patients a. Verifies patient identification with at least 2 identifiers b. Recognizes the mechanisms that result in medical errors c. Participates in effective and safe hand off and transitions of care 2. Provides cost-conscious medical care a. Demonstrates an awareness of and responsiveness to the system of health care b. Able to call effectively on other resources to provide optimal care to patients 3. Coordinates team based care a. Appropriately utilizes consultation and referrals to specialists in the management and comanagement of surgical conditions.

4 Syllabus: 1. Neck Masses a. List the differential diagnoses of anterior cervical triangle, midline, and low neck masses in children and adults b. Describe appropriate measures for evaluation and management of anterior cervical, midline and low neck masses c. Discuss the role of cervical lymph node biopsy in the evaluation of neck masses 2. Breast Disease 2. Breast Disease a. List the differential diagnoses for breast masses b. Identify predictive factors that may indicate benign vs. malignant disease via history-taking and physical examination c. Observe, evaluate and interpret mammograms, as appropriate, in differentiating between normal anatomy vs. breast cyst vs. fibroadenoma vs. breast carcinoma d. Discuss evaluation and treatment plan for fibroadenoma vs. asymptomatic and symptomatic fibrocystic disease e. Outline breast cancer types and staging f. Identify treatment options for local, regional and systemic breast cancer, including consideration of surgical, non-surgical, and combination therapy g. Discuss the evidence-based rationale for using adjuvant chemotherapy, radiation and hormone therapy in treating breast cancer h. Identify prognostic factors and survival rates for breast cancer according to clinical stage i. Outline the long-term plan for local recurrence and metastatic forms of breast cancer, e.g. plan for follow-up and management 4. Skin and Soft Tissue a. Differentiate between an abscess and cellulitis b. Based on physical examination, differentiate between subungual hematoma vs. paronychia vs. felon c. Describe the management of ingrown toenails d. Compare and contrast the various types of pigmented skin lesions, benign and malignant, in terms of distinguishing characteristics, e.g. various types of nevi, basal cell carcinoma, seborrheic keratosis, dermatofibroma, malignant melanoma e. Discuss the differential diagnoses of lymphadenopathy in the neck vs. supraclavicular area vs. axilla vs. groin f. Describe the assessment, diagnostic confirmation, and treatment of basal and squamous cell carcinoma and malignant melanoma g. Identify the indications for and administration of tetanus prophylaxis h. Identify the clinical signs/symptoms and management of wound infections, including cellulitis, furuncle, carbuncle, hidradenitis suppurtiva, lymphangitis, gangrene i. Discuss various wound closure options, circumstances, and complications for each.

5 5. Abdominal Pain a. Discuss the differential diagnoses and plan for work-up of acute abdominal pain b. Discuss the differential diagnoses and plan for work-up of chronic abdominal pain c. Differentiate between a non-surgical and surgical abdomen d. Gastroenterology: Esophagus, Stomach and Duodenum 6. Gastroenterology: Esophagus, Stomach and Duodenum a. List indications, risks, benefits and complications of esophago-gastro-duodenoscopy (EGD) b. Explain the evaluation and management of peptic ulcer disease (PUD) c. Explain the evaluation and treatment of ischemic bowel d. Describe the evaluation and treatment of a perforated viscous e. Describe the evaluation and treatment of bowel obstruction f. Develop an assessment and plan for treatment of a patient with any of the above conditions 7. Gastroenterology: Biliary Tract Disease a. Outline the differential diagnoses and diagnostic work-up for suspected biliary tract disease b. Discuss the management decisions and treatment options for diagnosed cholelithiasis c. Develop an assessment and plan for treatment of a patient with biliary tract disease and cholelithiasis 8. Gastroenterology: Colon and Rectal Disease a. Identify a routine primary care screening plan for colorectal cancer b. Outline a routine diagnostic plan for occult lower GI bleed, hematochezia, massive lower GI bleed. c. List indications, risks, benefits and complications for colonoscopy, sigmoidoscopy (flexible and rigid) d. Compare colonoscopy vs. barium enema in terms of patient preparation, patient comfort, cost and relative usefulness e. Observe, differentiate and evaluate radiographic imaging appearance for the following: diverticulosis, diverticulitis, inflammatory bowel disease, colon/rectal polyps and colorectal cancer f. Identify treatment options for local, regional and systemic colon cancer, including consideration of surgical, non-surgical, and combination therapy g. Discuss the follow-up protocol for post-surgical colon cancer patients h. Know the indications, risks, advantages/disadvantages and complications of an ostomy 9. Benign Perianal Disease a. Differentiate between external and internal hemorrhoids on physical exam. Describe the anatomical differences b. Compare and contrast the four clinical stages of hemorrhoids c. Discuss the etiology and predisposing conditions for hemorrhoidal disease. d. Outline the signs/symptoms of external and internal hemorrhoids e. Describe the non-operative and operative management options for external and internal hemorrhoids f. Describe the various types of perianal infections, including perianal abscesses g. Outline the signs/symptoms, physical findings, and management plan for perianal infection h. Outline the signs/symptoms, physical findings, and management plan for a pilonidal cyst

6 i. Outline the signs/symptoms, physical findings, and management plan for an anal fissure j. Develop an assessment and plan for treatment of a patient with a perianal infection, pilonidal cyst, and anal fissure under surgeon supervision 10. Hernia a. Compare and contrast indirect and direct hernias, including anatomical and developmental differences b. Identify predisposing clinical conditions for inguinal hernias c. Compare and contrast indirect, direct and femoral hernias in regard to relative frequency, age and gender d. Define sliding hernia, incarcerated hernia and strangulated hernia e. Outline the clinical presentation and treatment of a femoral hernia f. Discuss the etiology, natural history, and complications related to an umbilical hernia in an infant and adult g. Develop an assessment and plan for treatment of a patient with an umbilical hernia h. Identify the factors contributing to formation of an incisional hernia and the management protocol i. Outline postoperative instructions for hernia repair 11. Vascular a. Discuss asymptomatic aortic aneurysms of various sizes, identifying the follow-up plan for management b. Identify the current noninvasive tests for extracranial cerebrovascular disease, indications for arteriography and surgical intervention c. Discuss diagnostic, operative and non-operative management of chronic venous insufficiency (with and without ulceration) and varicose veins d. Describe evidence-based practice for choosing conservative vs. surgical management of claudication e. Describe the differential diagnosis and evaluation process for a patient presenting with a swollen leg f. Discuss noninvasive and invasive testing procedures for venous valvular incompetence and deep venous thrombosis g. Develop an assessment and plan for treatment of a patient with (non operative and operative) acute extremity ischemia which may be due to occlusive arterial disease, arterial emboli, vascular trauma, aneurysm thrombosis h. Understand fluid resuscitation options and compare and contrast crystalloid and colloid options based on presentation and electrolyte abnormalities i. Compare and contrast presentation and treatment of coronary artery blockage and the corresponding vessel involved 12. Endocrine/Hematology a. Discuss the possible complications and therapies of thyroid and parathyroid surgeries b. Discuss the possible complications and therapies of adrenal insufficiency and emergent surgery c. Understand indications and options for emergent transfusion during a trauma situation.

7 Assessment: 1. Assessment by the Surgical Team on a daily basis through direct observation 2. Formal evaluation at the completion of the rotation by the Surgical Team Reading Assignments Block/Week Schedule: PGY-1 Residents MON TUES WED THURS FRI AM Surgery Surgery Surgery Surgery Surgery PM Surgery Surgery Continuity Clinic FM Lectures Surgery

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