General Surgery - Red PGY 1

Length of Rotation: 2 Months

Goals

Riverside County Regional Medical Center will provide a learning environment for the PGY-1 resident to develop cognitive and technical skills in management of breast disease, hernias as well as basic principles of fluid resuscitation and electrolytes. Clinically, residents will assess surgical pathology pre-operatively, develop clinical judgment on managing these issues, and learn operative skills to address the problem. Careful postoperative care and follow up will be emphasized.

Objectives

Medical Knowledge

• Describe the anatomy of the breast.
• Explain the hormonal regulation of the breast.
• Summarize the incidence, epidemiology, and risk factors associated with breast cancer.
• Distinguish between these common entities in the differential diagnosis of breast masses: 
  • fibroadenomas, (Score)
  • fibrocystic disease
  • cysts
  • fat necrosis
  • abscesses
  • cancer
• Explain the general indications, uses, and limitations of mammography.
• Discuss the principles and historic context of the basic options available for the treatment of breast cancer such as: 
  • Radical mastectomy
  • Modified mastectomy
  • Lumpectomy and axillary dissection
• Management of 
  • Nipple discharge (Score)
  • Galactocelle (Score)
• Outline the diagnostic work-up and the differential diagnosis of various forms of nipple discharge.
• Explain the use of tumor, nodes, and metastases (TNM) staging in the treatment of breast cancer.
• Summarize the rationale for using a team approach to facilitate the complex discussions and explanation of options for the newly diagnosed breast cancer patient prior to definitive treatment (e.g., team of oncologist, surgeon, plastic surgeon, and radiation therapist).
• Discuss several causes of gynecomastia and outline an appropriate work-up. (score)
• Consistently apply basic science principles to common clinical situations
• Describe the potential complications arising from disorders in electrolytes and in under or over resuscitation.
• Describe the management of glucose in the diabetic patient.
• List etiologies for persistent high NGT output in the postoperative patient, or patient with small bowel obstruction.
• Describe the clinical presentation of a patient with hernias, abscesses, biliary disease,
• List at least seven etiologies for small bowel obstructions and ileuses.
• List the differential diagnosis of the patient with chest pain, low urine output, hypotension, hypertension, and hypoxia.
• Describe the important history and data to be taken prior to central line placement.
• Discuss clotting factors and how they interact (coagulation cascade).
• Discuss the role of the following factors in maintaining homeostasis in the coagulation pathways: 
  • Protein S
  • Platelet granules
  • Protein C
  • Endothelial cell
  • Platelets
  • Antithrombin III
• Describe the alternatives of treatment for the patient with an acute abdomen according to the specific etiology. 
  • Acute Cholecystitis
  • Acute Appendicitis
• Describe the anatomy, clinical presentation and complication of non-operative management of hernias.
• Name the most common hernia types and explain their pathophysiology.
• Describe the etiology, pathophysiology and therapeutic for inflammatory bowel diseases including ulcerative colitis and Crohn's disease.
• Define a Richter's hernia and describe the clinical presentation.
• Define a sliding hernia and describe its repair.
• Differentiate between incarceration and strangulation.
• Illustrate the use of diagnostic studies in the work up of complicated hernias.
• Describe the surgical techniques for the patient with a hernia, according to its different types.
• Promptly identify the potential complications of a hernia repair and treat them appropriately.
• Discuss wound care management in the emergency department and other settings, including management of drains and tubes inserted into various body cavities. (Score)
• Explain the characteristics of basic surgical skill, including: sterile technique,
• Incisions, wound closures, knot tying, handling of tissues and selection/use of operating instruments
• Consistently apply basic science principles to common clinical situations.
• Fundamentals of surgical nutrition including nutrition evaluation as well as routes of access, TPN, eternal nutrition, and nutritional supplements.

Assessment

• During the formative evaluation at the end of the rotation.
• Annually at the in-training examination

Patient Care

• Establish basic proficiency in providing pre-operative and post-operative care (writes appropriate pre-op and post-op orders for floor patients, handles nursing calls appropriately, and manages most routine post-operative care with minimal intervention by supervisor).
• Take an appropriate history to evaluate patients with general surgical issues to include: 
  • A complete history of present illness
  • Presence of any co-morbidities
  • A review of social and family history impacting the present problem
  • A complete review of systems
• Develop a proficiency in evaluation and interpretation of the different diagnostic modalities including: X-Rays, ultrasounds, CT scans, Contrast studies and MRIs.
• Discuss treatment options, risks and potential complications of patients with general surgical issues.
• Demonstrate skill in basic surgical techniques, including: 
  • Knot tying
  • Exposure and retraction
  • Knowledge of instrumentation
  • Handling of laparoscopic instruments
  • Incisions
  • Establishing of pneumoperitoneum
  • Closure of incisions

Assessment

• Patient care and technical skills will be assessed by the attending surgeon in a daily basis.
• Technical skills will be assessed at the skills laboratory.
• During the formative evaluation at the end of the rotation

Professionalism

• Understand the importance of honesty in the doctor-patient relationship and other
• Interactions.
• Learn how to participate in discussions and become an effective part of rounds, attending staff conference, etc.
• Complete all assigned patient care tasks for which you are responsible or provide complete sign out to the on-call resident.
• Maintain a presentable appearance that sets the standard for the hospital this includes but is not limited to adequate hygiene and appropriate dress. Scrubs should be worn only when operating or while on call.
• Provide an appropriate orientation and guide all medical students as to their roles and responsibilities during the rotation.
• Complete the required Professionalism in Surgery curriculum for the current month (See Attached Schedule)

Systems-Based Practice

• Understand the cost implications of medical decision-making
• Develop a cost-effective attitude toward patient management.
• Complete your required System Based Practice project

Practice -Based Learning & Improvement

• Demonstrate the ability to: 
  • Evaluate published literature in critically acclaimed journals and texts
  • Apply clinical trials data to patient management
  • Participate in academic and clinical discussions
• Use the library and databases on on-line resources to obtain up to date information and review recent advances in the care of the surgical patient.
• The completed PLP will be added to the resident's electronic portfolio reviewed at the semi-annual evaluation.

Interpersonal & Communication Skills

• Work as effective team members
• Cultivate a culture of mutual respect with members of nursing and support staff
• Complete the Interpersonal and Communication Skill curriculum for the quarter (See Attached Schedule)

Assessment

• Formative evaluation will be completed by the attending faculty at the end of the rotation.

Conference Attendance: Conference attendance is mandatory at the hospital in which you are rotating. The ACS weekly and Basic Science Lecture is required for all PGY 1 & 2 residents and is held at RCRMC, if you are on another rotation, you are released from your duties to attend this lecture series.