OUTLINE FOR DESCRIPTION OF ROTATION

ROTATION: Surgery

PRECEPTORS: Drs. Stephen R. Bartos, Christopher B. Davies , William B. Davies, Chris Fox, Paul S. Fox,
Kevin Hart, Arche J. Pequet, and David D. Schmitt,

Shawn Hake, P.A., Nicole Meyer, P.A., Vasu Kumar, P.A. (Resident/Student Coordinator)

COORDINATOR: Dr. Christopher B. Davies

DURATION: Two Months (PG-I)

1. GOALS/OBJECTIVES OF ROTATION:

--- Strengthen and refine surgical diagnosis and treatment skills, especially for common problems.

--- Learn preoperative evaluation, assessment of surgical risk and pre- and post-operative care.

--- Differentiate emergent surgical vs. non-emergent surgical or medical problems.

--- Learn principles of and practice surgical assisting, lesion removal, and quality wound closure that minimizes scarring.

--- Develop skills in common outpatient surgery typical for a family physician

2. EXPECTATIONS OF ROTATION:

The coordinating fourth year surgery resident will assist in allocating patients and at the beginning of each day the team should review upcoming cases and decide who will be accepting day surgery patients for work up. Patient allocation should depend on your availability the following morning for doing the H&P and assisting in the OR (avoid taking these patients if you were on call the night before or if you have family practice clinic the next morning). Your responsibilities include:

a. Perform/dictate H&P’s, write admit/pre-op notes, make daily post-op rounds and make progress notes, and dictate discharge summaries on your assigned patients. Rounded daily to discuss all patients with the attending or PA.

b. Assist in the OR of your patients and anticipate case discussion with attendings (review anatomy and pathophysiology in advance). Preparation and interest will increase what you do in the OR. Arrive early and ask anesthesiologist if you can participate with procedures, especially intubation. If you are having difficulty working with anesthesiology, contact Dr. Mike Woods for help.

c. See ER admissions promptly for all seven surgeons. Talk directly to the ER physician and unit clerk letting them know that you’d like to see surgical patients in advance of the attendings and in advance of the ER physician. Check for your name on the ER physician list just after the name of the surgeon on call.

d. On-call – Once per week and every other Friday and Saturday. Do not take new cases the following day and you must leave by noon after rounding on previously admitted patients, unless you were not called in the previous night on call.

e. Didactic discussions – use the “core discussion check list” attached and check off topics discussed asking attendings to discuss remaining topics with you as time allows (e.g. in the surgeons lounge).

f. Friday morning educational conference (you will be assigned a case - patients seen in the last 7 days). Provide a brief summary of the case and then provide a relevant review of the problem based on your literature search.

g. Assist with support and teaching of M3 students

h. Complete post-test one week before end of rotation and discuss questions with Dr. Davies.

i. One week ambulatory experience (third or fourth week of the rotation – this experience must be scheduled and you must be released from in-patient responsibilities by 9:00am. Round on your in-patients and talk to the PA before you leave. Keep a close eye on the schedule in out-patient or the ambulatory surgical center or out-patient family practice procedures (lumps and bumps, etc.). Have no more than one day of call during this week (ask other team members to accept admissions if possible up till 4:00pm). If there are no relevant procedures being done out-patient, use the following list of other things to do with this time.

- Attend surgeons out-patient clinic (work up new patients and see post-op follow ups, esp.
wound care)

- Contact Dr. Thomas Korkos and request working with him on his out-patient surgical
cases (phone: 970-5600)

- Ask anesthesiology to participate in procedures such as intubation and lines

- Other procedures such as vasectomy (urologists and surgeons), central lines, etc.

3. SUGGESTED PREPARATION/REFERENCES:

a. Practice suture/knot typing/wound closure using Ethicon boards provided. Surgical assistants can work with you on these skills.

b. Carefully review articles on pre-operative assessment.

4. ORIENTATION:

--- A day or two before, ask a resident to take you to each area you will work and discuss what you
will do.

--- Dr. Chris Davies (or designee) will meet with you for an hour on the first day or two of the rotation to discuss. Any problems with the rotation or confusion about your role, discuss with Dr. Davies immediately.

5. TYPICAL DAY/WEEK:

--- H&P's should be done the morning before surgery at 5:30 - 7:00 a.m. and dictated on "stat" line (2121). Write a brief pre-op note on the chart.

--- Surgeries generally begin at 7:30 - 8:30 a.m. and continue until early afternoon.

--- Rounds - try to write progress notes in the morning before attending's round. Maintain a list of your assigned patients and what needs to be done – round on the sickest patients first.

--- In the afternoon, you will either be released to go to your family practice clinic or finish rounding and complete other follow ups on patients. When on call, expect evening admissions, consults, and pages regarding in-patients.

--- As time permits, go to the ER to sew up lacerations, evaluate potential admissions, and be immediately available for new admissions.

--- Go to ambulatory surgery center for cases as directed by Dr. Chris Davies.

6. WORK-UPS/WRITE-UPS:

Promptly complete H&P dictations, discharge summary, and daily progress notes/orders. Surgeons dictate their own op note, while you write a brief op note in the chart.

7. PROCEDURES:

If you don’t search them out, you may miss valuable opportunities to do outpatient lesion removals, insert lines, do vasectomies, etc. Go to the OR early on your cases and ask the anesthesiologist if you can participate with intubations and line placement.

8. AVAILABLE EDUCATIONAL EXPERIENCES/CONFERENCES:

At least one resident on the team should be freed up to attend each of these sessions.

EVENT:	DAY:	TIME:	LOCATION:
Residency Morning Report	Monday	7:30 a.m.	Resident Room
All Staff Conference	Tuesday	7:30 a.m.	Treiber E
Oncology Review (General Surgeon Cases)	Wednesday (once a month)	7:30 a.m.	Treiber E
Wednesday Afternoon Conferences	Wednesday	12-4:00 p.m.	Residents room
Residency Morning Report	Thursday	7:30 a.m.	Residents room
Surgery Morning Conference	Friday	6:30 a.m.	Room K
Didactic Sessions	See Items 2g & 2h above

* Conferences sites above are subject to change – check the schedule on the monitor (especially for the one Oncology Review Conference for General Surgery).

Exception to attending these conferences - Infrequent exceptions to the attendance requirements include unusual and very relevant learning opportunities or critical care experiences in follow up of your patients.

9. IMPACT ON OFFICE SCHEDULE: CONFERENCES AND FAMILY PRACTICE MORNING ROUNDS:

a. Office Schedule - ½ day per week (afternoon only-plan your schedule carefully as you must not be post-call). Canceling your clinic per acutely ill patients must be cleared by Dr. Fay. If you anticipate this could happen, let him know early.

b. Wednesday afternoon Conferences (see above) and Thursday Morning Report - Preceptors understand that you be excused with rare exception for highly educational circumstances. When possible, watch for cases assigned to you that may conflict with these conference requirements.

c. Attend Family Practice morning rounds as possible--at least one of the PG-I's should be present at morning rounds and assignment of cases on the surgery service should be considered so that one PG-I is available for morning rounds on Thursdays.

10. CALL (and shared call):

See section 2 – in-house call Monday through Friday and home call Saturday or Sunday. Be available for attending emergencies or codes called in the hospital while in-house. Work with ER physicians if time permits to improve suturing skills.

11. WEEKEND REQUIREMENTS:

For Saturday or Sunday call, be prepared to come in immediately. Ask attendings if there are any outpatient procedures being done Saturday. Assist with rounds, but leave no later than 12:00p.m. on post call days.

12. VACATION/TIME OFF:

One week is allowed during the entire two month rotation.

13. EVALUATION:

Meet with Dr. Chris Davies in the beginning, middle and end of the rotation – schedule these times at the start of the rotation. Discuss specific expectations, the evaluation form, and how you will be evaluated by individual attendings. In the last week, discuss any questions you have about the surgery post-test results.

RBL:ejb

Revised: 05/20/05 - PHG:lmc
SURGERY: CORE DISCUSSION CHECKLIST

TOPIC SURGEON DATE DISCUSSED

Fundamental Surgical Principles:

Basics of order writing on this service

Essentials of pre-op evaluation

- medical evaluation/assessment of surgical patient

- medical evaluation/assessment of elderly patient

- prophylaxis of infection including endocarditis

Essentials of post-op care

- standard orders and effective pain

- management

- approach to post-op fever and wound infection

- what to check for when rounding on post-op patients

and what orders you can write when rounding

Nutritional support of surgical patient

Fluid, electrolytes, metabolic response to surgery

Wound management and lesion excision

Specific Surgical Problems:

Abdominal pain and acute abdomen

Bowel obstruction

Gastrointestinal bleeding

Biliary disease

Pancreatic disease

Hernia

Anorectal (hemorrhoids, abscess, fissures)

Peripheral vascular disease

- evaluating claudication

- cerebrovascular disease

Breast (cancer, lumps, and cysts)

Endocrine (indications for thyroid surgery including proper

follow-up and complications such as hypocalcemia)

Skin abscess and pilonidal disorders

Minor burns

Trauma

- initial evaluation of the traumatized patient

- approach to common injuries (bowel, spleen/liver)

Varicose veins

Residents: Keep this sheet with you and review regularly with Dr. Chris Davies to ensure complete coverage of these topics. Return this completed form to Lisa. Thanks.

RBL:ejb

Reviewed: 05/20/05 – PHG:lmc