ROTATION: General Surgery (Oncology-Endocrinology) LOCATION:  VUMC Level:PGY III - Endocrine

 

I.                   Knowledge:

By the completion of the third year, the general surgery resident should be able to:

1.      Demonstrate normal thyroid anatomy in the operating room, including 

The thyroid gland, its vascular supply and venous drainage, the parathyroid glands, recurrent laryngeal nerves, strap muscles and platysma.

2.      Describe normal variants in recurrent laryngeal nerve anatomy including                

frequency.

3.      Describe normal thyroid and parathyroid embryogenesis.

4.      Outline the normal thyroid hormone synthetic pathway including iodine

      metabolism and feedback mechanisms.

5.      Outline the normal calcium and parathyroid hormone pathway.

6.      Outline appropriate lab testing for the following clinical scenarios, including interpretation of predicted test results:

a.       Thyroid nodule

b.      Goiter

c.       Hyperthyroidism

d.      Hypothyroidism

e.       Hypercalcemia

7.      Develop an algorithm that includes pertinent history, examination findings

And diagnostic evaluation of:

a.       A palpable thyroid nodule

b.      A nonpalpable nodule discovered on ultrasound performed for non thyroid pathology

c.       Hypercalcemia

8.      Recognition and treatment of common postoperative complications:

a.       Hematoma

b.      Hypocalcemia

c.       Thyroid storm

d.      Voice changes

9.      Outline algorithms for the evaluation and treatment of:

a.       Well-differentiated thyroid cancer

b.      Medullary thyroid cancer

c.       Thyroid lymphoma

d.      Anaplastic thyroid cancer

10.  Describe risk factors for well-differentiated thyroid cancer, medullary   

Thyroid cancer and anaplastic thyroid cancer

11.  Outline the staging and prognosis in thyroid cancer

12.  Outline the complete evaluation and management of nontoxic multinodular goiter and substernal goiter

13.  Describe the management of intraoperative recurrent nerve injury

14.  Describe the approach for reoperative thyroid and parathyroid surgery

 

II.                 Skills:

 

1.      Obtain a focused history, perform an examination and institute the diagnostic evaluation of a patient with the following conditions:

a.       Thyroid nodule

b.      Goiter

c.       Hyperthyroidism

d.      Hypercalcemia

2.      Palpate and describe a thyroid nodule

3.      Palpate and describe a goiter

4.      Identify exophthalmos

5.      Perform a fine needle aspiration biopsy of a palpable thyroid nodule

6.      Perform the initial steps in thyroid surgery, including

a.       Patient positioning and marking

b.      Skin incision and raising subplatysmal flaps

c.       Opening strap muscles

d.      Identification of recurrent laryngeal nerve

e.       Ligation of the superior and inferior pole vessels

f.        Mobilization of thyroid lobe

g.       Close strap muscles, platysma and skin

7.      Interpret thyroid ultrasound and parathyroid scan

8.      Interpret intra-op intact PTH values

ONC ENDO 3	SCORE
Understands thyroid & parathyroid anatomy	Green	Yellow	Red
Understands neck fascial planes	Green	Yellow	Red
Able to raise subplatysmal flaps	Green	Yellow	Red
Understands surgical options for thyroid CA	Green	Yellow	Red
Understands hyperparathyroidism	Green	Yellow	Red
Able to w/u thyroid nodule	Green	Yellow	Red
Understands concept of neck dissection	Green	Yellow	Red
Understands the basics of thyroid and parathyroid ultrasound	Green	Yellow	Red

ROTATION:  Pediatric Surgery          LOCATION:  VCH  LEVEL:          PGY III

1.         Knowledge:

• Understanding of general principles of care of children with surgical conditions.

• Understanding of differences in anatomy and physiology.

• Understanding of fluid and electrolyte and nutritional management in childrenUnderstanding of pain control.  

• Understanding of pathophysiology of common surgical conditions in children including pyloric stenosis, intestinal obstruction, appendicitis, foreign body of esophagus and airway, etc.

• Management of critically ill children.  Management of stable neonate.

• Understanding of pathophysiology of surgical conditions in neonates and older children including esophageal arrests, congenital diaphragmatic hernia.

•  Hirschsprung's disease, intestinal atresia, intussusception, Wilms tumor, neuroblastoma, etc.

2.         Skills:

Stabilization and assessment of pediatric trauma patient airway management in older children.  Venous access in younger children.  Interpretation of specialized radiologic studies including upper GI series, barium enema, CT scan, MRI, and Radionuclide scans.  Surgery for pyloric stenosis and inguinal hernia in infants.  Complicated appendicitis, vascular access in infants and intestinal obstruction in older children.

3.         Other Attributes of Resident:

Understanding and development of a system to provide cost-efficient surgical care.

4.         Continuity of Care:

Active participation in preoperative assessment involving regular attendance of the outpatient clinic, provision of inpatient and emergency room consultation.  Understanding the principles of early and late follow-up for complex surgical problems of childhood through participation in outpatient clinic.  Preoperative assessment of all patients is expected including both inpatients and outpatients

Pediatric Surgery 3	Score
Reiterates understanding of fluids, electrolytes, and feeding in neonates, infants, and children	Green	Yellow	Red
Demonstrates good examination for appendicitis	Green	Yellow	Red
Understands differences b/t omphalocele and gastroschisis	Green	Yellow	Red
Understands physiology of congenital diaphragmatic hernia	Green	Yellow	Red
Understands w/u & treatment of Pyloric Stenosis	Green	Yellow	Red
Demonstrates good knowledge of neck anatomy as it pertains to branchial cysts and thyroglossal duct cysts	Green	Yellow	Red

 

 

 

ROTATION:  General Surgery (Gold)        LOCATION:              VUMC and NVAMC      LEVEL:  PGY III KPT Resident Manual 1.         Knowledge: ·         Evaluation and pre-, intra-, and postoperative management of surgical problems in patients with end stage renal disease including dialysis access, kidney and pancreas transplantation. ·         Evaluation, pre-, intra-, and postoperative management patients with pancreatic and hepatobiliary disease including liver transplantation. ·         Evaluation, pre-, intra-, and postoperative management of morbidly obese patients undergoing bariatric surgery. ·         Understand hepatobiliary, pancreatic and gastrointestinal anatomy and physiology. ·         Understanding of basic principles of transplant immunology including HLA and histocompatibility testing, chronic immunosuppression, and diagnosis and treatment of allograft rejection. 2.         Skills: ·         Perform kidney transplants; i.e., exposure of iliac vessels and perform the vascular anastomoses and ureteroneocystostomy. ·         Participate in pancreas transplants, i.e. exposure of iliac artery and distal IVC, perform vascular anastomoses and enteric drainage procedure, duodenojejunostomy. ·         Participate in multi-organ deceased donor procurements. ·         Perform common intermediate level biliary procedures and general surgical operations including morbid obesity procedures.  Management of coagulopathy, hepatic failure, encephalopathy and ascites. ·         Able to interpret all laboratory and radiological studies. 3.         Other Attributes of Resident: ·         Participate in daily rounds, outpatient clinics (minimum of 2 half days per week), and conferences including selection committee meeting,  M & M, grand rounds and resident teaching conference. ·         Participate in immunosuppression management. ·         Carry out patient management decisions in consultation with PGY5 and attending transplant surgeon on Gold service. ·         Participate in student teaching. ·         Reliable, honest, good communication skills, appropriate judgment. Gold R3 Score Bookwalter setup in LUQ Green Yellow Red Knowledge of Donor harvest concepts Green Yellow Red Creation of bowel anastomosis Green Yellow Red Division of bowel mesentery for mobilization Green Yellow Red Proper construction or Roux-en-Y limb Green Yellow Red Postgastrectomy complications Green Yellow Red Able to close instrument while “palming” needle holder Green Yellow Red Performs venous and arterial anastomoses of kidney transplants Green Yellow Red Able to perform dissection and gain control of the iliac artery and vein Green Yellow Red Sets up retractor for exposure of the iliac fossa Green Yellow Red Independently exposes vessels for creation of an AVF or AVG Green Yellow Red Vascular anastomoses for AV access Green Yellow Red

 

ROTATION:  General Surgery          LOCATION:  NVAMC        LEVEL:          PGY III

1.         Knowledge:

The PGY-III resident should begin to understand the basics of claudication, rest pain, cerebrovascular disease, mesenteric vascular disease, and aneurysmal disease.  They should begin the year with a core knowledge of general surgery with beginnings of understanding of the controversies and evolving alternatives of therapy in both general and vascular surgery.  They should begin to how to access the literature to help in clinical decision making.  They should begin to initiate and work-up the basic problems of general and vascular surgery, including arterial and venous diseases and the various areas of general surgery.  They should have a basic understanding of the anatomy involved in all vascular and general surgical cases.  They should begin to take over the majority of postoperative patient care.  They should regularly assist on all major general and vascular cases and perform those within their purview.

2.         Skills:

Operative skills should be vastly improving at this point.  They should begin to become more of an operator rather than a first assistant.  They should not only be able to assist PGY-I residents in primary PGY-I level cases, but should also begin to assist chief residents in more major cases.  Third year residents should be expected to perform under close supervision several vascular cases during their rotation including carotid endarterectomy and femoral popliteal bypass.  In the general surgical role, PGY-III should begin performing recurrent hernia repairs, open biliary procedures, breast procedures, endocrine procedures, and colon resections.

3.         Other Attributes of Resident:

Family and patient interaction are crucial.  The PGY-III should perform all the vascular and general surgery consultations and present a concise, accurate report to either the chief resident or attending surgeon.  They should begin to become actively involved in teaching the junior residents and students and also begin partaking in the teaching conference at an active level.

The PGY III resident will actively participate in the team's clinic weekly to provide continuity of care for the patient and for the resident.    

VA General Surgery 3	Score
Completes EGD’s and Colonoscopy independently & completely	Green	Yellow	Red
Completes hernia repairs independently	Green	Yellow	Red
Completes line insertions independently	Green	Yellow	Red
Assists on Lap Chole from R side of table	Green	Yellow	Red
Manages ICU patients well	Green	Yellow	Red
Systematically evaluates abdominal CT’s	Green	Yellow	Red
Good decision-making in the outpatient clinic	Green	Yellow	Red