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Surgical Resident Curriculum
Editors
Section Editors
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Web Editors: John
Tarpley, M.D.,
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SURGICAL RESIDENT
CURRICULUM
______________________________
FOURTH EDITION
Editors
Sherralyn S. Cox, Ph.D., Walter E. Pofahl, II, M.D., and
Walter J. Pories, M.D.
Section Editors
Part One Eric A. Toschlog, M.D.
Part Two Carl E. Haisch, M.D., Walter E. Pofahl, II, M.D.
Part Three Scott G. Sagraves, M.D.
Part Four Jeffrey W. Hazey, M.D., Rosa E. Cuenca, M.D.
Part Five John C. Fitzpatrick, M.D., J. Scott Roth, M.D.
Part Six Jeffrey C. Pence, M.D.
Part Seven Walter E. Pofahl, II, M.D.
Ó 2002 The Association of Program Directors in Surgery
Arlington, Virginia
This
curriculum is dedicated to the memory of Dennis W. Jahnigen (1947-1998) who served as
leader, confidante, and mentor throughout much of the period of project
development.
We gratefully acknowledge the
funding support that we have received from The John A. Hartford
Foundation/American Geriatrics Society project, “Increasing Geriatrics
Expertise in Surgical and Related Medical Specialties.” This support has
enabled us to work to integrate the information on the geriatric aspects
of surgical care throughout our curriculum, as was the wish and plan of
Dr. Jahnigen.
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The Editors
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CONTRIBUTORS
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Ira N. Adler,
M.D. Robert E. Berry,
M.D. Donald Bode,
M.D., Ph.D. Rebecca L. Cali,
M.D.
Sherralyn S.
Cox, Ph.D. |
Rosa
E. Cuenca, M.D |
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Joseph R.
Elbeery, M. D. John C.
Fitzpatrick, M.D. M. Beth Foil,
M.D. Nicola A.
Francalancia, M.D. Paul Friedmann,
M.D.
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Carl E. Haisch,
M.D. Michael
H. Handler, M.D.
G. Patrick
Kealey, M.D. |
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Janice F.
Lalikos, M.D. Peter R.
Lichstein, M.D. Larry R. Lloyd,
M.D.
William M.
Meadows, Jr., M.D.
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Lori J. Morgan,
M.D. Alva J. Morris,
M.B.A. Douglas F.
Naylor, Jr., M.D. James A.
O'Neill, Jr., M.D. Timothy N.
Patselas, M.D. Jeffrey
C. Pence, M.D. |
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Walter
E. Pofahl, II, M.D. Susan E. Pories,
M.D. Walter J. Pories,
M.D. C. Steven
Powell, M.D. Lisa
Rechtschaffen, M.D. William G. Rhea,
Jr., M.D.
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Robert S.
Rhodes, M.D. G. Alec Rooke,
M.D., Ph.D. J.
Scott Roth, M.D. Grace S. Rozycki,
M.D. Scott
G. Sagraves, M.D. Joshua Schwartz,
M.D. |
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Carol EH
Scott-Conner, M.D., Ph.D. Gordon
B. Sherard, III, M.D. Jay C. Smout,
Ph.D., C.H.E. Michael D.
Stone, M.D. Melvin S.
Swanson, Ph.D. Joseph J. Tepas,
III, M.D.
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Eric A. Toschlog,
M.D. Jon A. van
Heerden, M.D. Leslie Webster,
III, M.D. Lucy A.
Wibbenmeyer, M.D. William A.
Wooden, M.D. James P. Worden,
Jr., Pharm.D.
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PREFACE TO THE FOURTH EDITION
The fourth edition of the Surgical Resident Curriculum emphasizes the principle that positive educational outcomes are best attained if the goals, objectives, and expected outcomes are clearly defined for resident learners. The current curriculum revision includes: (1) competencies for surgical advances since publication of the third edition in 1999 and (2) refined and expanded objectives emphasizing the knowledge and skills needed for residents to gain expertise to meet the health care needs of their elderly patients.
Advances in science and technology continue in the dynamic field of surgery, including those advances in minimally invasive and robotic surgery, and in our understanding of molecular biology. Our aging population presents an ever-growing challenge. It is not uncommon to see 85-year-old patients undergo surgical procedures. Nor is it unusual for residents to communicate with the families of patients and patients in their ninth decade. We are grateful to the American Geriatrics Society and the John A. Hartford Foundation of New York City for providing the Association of Program Directors in Surgery (APDS) with funding for education to further the study and teaching of surgical geriatrics and for support of resident research and special interest group activities at surgical meetings.
We regard a curriculum as a road map for an educational journey. Just as in a trip across the United States, there may be many ways to get to the destination and there are a number of places to linger. Similarly, this curriculum document for the residency in surgery delineates competencies to be achieved while it facilitates choices. Surgical educators will tailor-make a curriculum for their own residents. This document can serve as a point of reference to faculty and education committees as they determine program priorities, to residents as they plan a course of action in their study and board preparation, and to program directors as they organize their documentation of education for the Accreditation Council for Graduate Medical Education (ACGME). As in previous years, to assist program directors, the Surgical Resident Curriculum is being made available electronically from APDS through these editors.
How could one use this curriculum? Here are several examples:
Select competencies from the curriculum as the basis for revising one’s existing residency content to meet the ACGME Outcome Project requirements
Direct the planning of rotations for residents by level
Guide a resident’s study program as he or she progresses through the various rotations
Provide a scaffold for the scheduling of formal lectures in basic science and the general surgical specialties
Help plan individual lectures and presentations (e.g., What should I cover in my presentation of hyperparathyroidism?)
Provide an outline of goals and objectives for the rotations through the surgical subspecialties
Organize reviews for ABSITE and the Qualifying and Certifying Examinations of the American Board of Surgery
Offer a "check-list" for general surgeons in practice to measure their competency
We are sure that you can think of other approaches as well. We offer you this guide with our best wishes for a challenging and rewarding residency. Good luck to you.
Sherralyn S. Cox, Ph.D.
Walter E. Pofahl, II, M.D.
Walter J. Pories, M.D.
ACKNOWLEDGEMENTS
It has now been more than fifteen years since the Association of Program Directors in Surgery (APDS) first supported the concept of a project to develop and disseminate a residency curriculum document representing surgical educators’ efforts to structure the extensive and complex knowledge, psychomotor skills, and attitudes that are Surgery. Department chairs, program directors, other surgical educators, and residents from a variety of institutions through the APDS provided conceptual guidance for the curriculum. Implementation has been facilitated by Mr. Tom Fise and Ms Liz Starnes at the Association.
The task of preparing the first edition of the Surgical Resident Curriculum fell to Jay C. Smout, Ph.D. His efforts in large part provided Surgery with its first national curriculum in 1992, following years of work on conceptual organization by Hazel M. Aslakson, Ed.D. and Walter J. Pories, M.D. The second edition, published in 1995 and headed by Sherralyn S. Cox, Ph.D. and Dr. Pories, saw content and organizational changes. M. Beth Foil, M.D. and Timothy N. Patselas, M.D rounded out the editorial team. The third edition, edited by Dr. Cox and Dr. Pories, continued refinement in 1999. Now, for the fourth edition in 2002, Walter E. Pofahl, II, M.D., and a group of surgeons as section editors have joined the team of Cox and Pories to provide new perspective to the project.
The American Geriatrics Society and John A. Hartford Foundation chose to fund the development of surgical geriatric materials through the existing team at East Carolina University because of the existence of the Surgical Resident Curriculum as a national curriculum vehicle. To date, nearly every surgical training program and many other entities such as libraries, bookstores, and practicing surgeons have placed orders with APDS to receive the document. More than 295 programs and individuals have requested and been provided electronic versions in addition to the Web version at the APDS site: http://www.apds.org/
Dissemination of the Surgical Resident Curriculum will undoubtedly serve as impetus for continuing discussions about what surgeons do and how they are educated to do it. We hereby acknowledge those of you who daily work to explicate the science and art that is Surgery.
Section 1.1
SURGICAL
RESIDENT CURRICULUM GOALS
Summary
Curriculum Goals:
The goal of the surgical curriculum is to assist program directors, faculty, and residents in their educational pursuits. Each program is required to have a clear set of goals that can be viewed as milestones or expectations, by level, for resident learners.
Specific Curriculum Goals:
· Create an organizational structure of academic, clinical, and technical criteria to facilitate the education of residents in general surgery.
· Provide an educational plan as an available guide for a diverse body of surgical programs, including: new programs, established programs, university- and community- based programs, public and private programs, urban and rural programs, five-year and six-year programs, and military-based programs.
· Maintain educational criteria that are congruent with the aims of the American Board of Surgery and the Residency Review Committee for General Surgery.
· Suggest teaching methodologies for expanding the number of ways to transmit knowledge, skills, and attitudes from faculty to residents.
· Establish the basis for evaluation activities tied to expectations of resident learning.
· Facilitate the self-directed study of residents via recommended readings and learning activities.
· Suggest learning experiences based on measurable objectives for the education of surgeons.
· Integrate principles of basic sciences with clinical experiences.
· Promote a broader understanding of the role of surgery and its interaction with other medical disciplines such as Internal Medicine, Psychiatry, and Pediatrics.
· Guide the mechanism for residents' progressive responsibility from initial patient care to complete patient management for all patient age groupings, from neonatal to the oldest-old.
· Provide surgical residents with a reference for functioning as teachers and consultants.
· Guide surgical residents to use research technology and skill in conducting studies that assist in solving surgical problems.
· Assist residents in achieving professional leadership and management skills.
· Promote the understanding of the economic, legal, and social challenges of contemporary and future surgery.
· Foster continuing education to promote lifelong individual initiative and creative scholarship.
GUIDELINES FOR RESIDENT EDUCATION IN SURGICAL GERIATRICS
Members of the Association of Program Directors in Surgery (APDS) Curriculum Committee and the Task Force prepared these curriculum guidelines for Surgical Geriatric Curriculum Development. The guidelines can be considered the starting point for a multifaceted program to assist surgical training programs organize and prioritize geriatric competencies for their general surgery residents. Since 1995, APDS has provided supporting structure for increasing geriatric knowledge and skills for general surgery residents, offering symposia, panel and workshop education sessions, and supporting reviews in the surgical geriatric literature for educators and practitioners. This work has been supported by generous funding from the John A. Hartford Foundation of New York City and the American Geriatrics Society (AGS), primarily through the project Increasing Geriatrics Expertise in Non-Primary Care Specialties. In the past year the AGS/Hartford Foundation has extended funding competitively to general surgery through the Geriatrics Education for Specialty Residents Program (GESR), a component of the broader project, Increasing Geriatrics Expertise in Surgical and Related Medical Specialties. In general surgery the following programs were selected to participate in the GESR initiative: University of California-Los Angeles, Yale University, University of Rochester, and East Carolina University.
The Surgical Resident Curriculum has integrated units, so that resident objectives related to care of the elderly patient are presented with, or immediately adjacent to, related surgical content. When one consults the table of contents, one can quickly determine if geriatric objectives are within a revised unit (e.g., Unit 2.2/2.2G, where "G" indicates "Geriatrics") or if the geriatric objectives are provided as a separate unit. This format allows for recognition of each contributor’s role.
The following guidelines provide the structural basis for increasing resident expertise in caring for the special needs of elderly patients.
CURRICULUM GOAL: Following study and implementation of a Surgical Geriatric Curriculum, the surgical resident will be prepared to manage or co-manage the health care needs of prospective surgical geriatric patients.
RESIDENT COMPETENCIES
I. PRINCIPLES OF NORMAL AGING
The resident will acquire a working knowledge of general principles of aging while recognizing the considerable heterogeneity of patients age 65 and older.
The general principles will include the study of:
1. Demography of aging
2. Biology of aging relative to age-related physiologic changes
3. Preventive geriatrics: health maintenance
The resident will be prepared to recognize, interpret, and manage the principal elements in the Psychology of aging that present as the patient’s psychologic status, cultural value system, and personally-preferred lifestyle.
Elements of the Psychology of aging will include applying principles of:
1. Neuropsychiatric aging: brain-behavior relationships (dementia, acute delirium/changes in mental states)
2. Hypothalamic function and regulation of body temperature
The resident will be prepared to identify age-related physiologic changes and apply that knowledge during surgical counseling and decision-making.
Age-related physiologic changes will encompass:
1. Aging relative to tissues, organ systems, immune functions, and nutritional needs
2. Endocrine and metabolic alterations (e.g., carbohydrate and insulin metabolism)
3. Changes in laboratory values (e.g., expected changes in normal blood chemistries)
PATHOPHYSIOLOGY IN THE ELDERLY PATIENT
The resident will develop clinical management strategies, considering the unique aspects of geriatric pathophysiology.
Knowledge of disease processes will include the study of:
1. Mortality: leading causes of death for those 65 and older
2. Morbidity: leading causes of disability
3. Factors affecting altered disease presentation
4. Comorbidity: chronic diseases superimposed on acute disease
5. Geriatric syndromes (dementia, failure to thrive, fractures, malnutrition, sleep problems)
The resident will be prepared to analyze and apply information about medication to principles of age-related pharmacokinetics, pharmacodynamics, and adverse drug reactions.
Physiologic and Psychosocial implications will build upon a working knowledge of:
1. Changes in drug metabolism and excretion
2. Adjustment of doses and age-specific side effects
3. Use of psychotropic agents and pain medications
4. Identification of possible adverse drug-drug interactions
5. Significance of financial problems imposed by polypharmacy
III. PREOPERATIVE ASSESSMENT OF THE ELDERLY PATIENT
The resident will modify his/her approach to evaluation and diagnosis in a manner that is effective, efficient, and in accord with the special needs and limitations of the geriatric individual.
Factors to consider will include:
1. Developing attitudes toward and communicating with the elderly; age bias
2. Establishing lines of communication with health care team: personal physician/geriatrician, social worker
The resident will be prepared to obtain and utilize patient data for decision making prior to surgery.
Full geriatric assessment of patient baseline data will include consideration of:
1. Functional capabilities: activities of daily living, mental and physiologic health
2. Psychosocial variables: ethnic factors, cultural mores, social supports, and community relations
3. Differences in health care preferences according to perspectives of patient, referring physician, and surgeon
4. Considering risks to desired surgical outcomes: comorbidity, frailty, and social supports
The resident will be prepared to implement interventions that minimize legal and ethical risks to the patient’s individual rights and liberties.
Interventions will require consideration of the following factors:
1. Weighing aggressive approach with patient’s right to autonomy: legal right to self-determination and perceptions of quality of life
2. Rights regarding competence and advance directives: informed consent, surrogate decision making, long-term care, extent of care, living wills, and decisions about death
3. Cost:benefit ratio determination
IV. OPERATIVE MANAGEMENT OF THE ELDERLY PATIENT
The resident will monitor and act upon coexisting requirements of care to maintain patient stability.
Monitoring of patient surgical needs will include:
1. Planning and supporting the selection and management of local, regional, and general anesthetics
2. Managing conscious sedation
3. Maintaining body temperature and metabolic homeostasis during surgery
4. Following Halsted’s Principles during surgical intervention
V. PERIOPERATIVE CARE OF THE ELDERLY PATIENT
The resident will determine and act upon the continuing needs of the surgical patient based upon patient communication and interaction, use of patient data, and analysis of surgical outcome.
Perioperative decisions will require:
1. Management of complications such as sepsis, cardiac problems, diabetes, pulmonary and renal failure.
2. Determining need for prophylaxis for common complications like DVT and PE, aspiration pneumonia
3. Sustaining patient with homeostasis, fluid management, ventilator support, wound and antibiotic management
4. Determining management for deconditioning, use of Foley catheters and NG tubes, use of invasive monitoring
5. Management of directive care issues such as life sustaining mechanisms: supportive care, extent of care issues
VI. LONG-TERM RECOVERY/REHABILITATION OF THE ELDERLY PATIENT
The resident will be prepared to utilize information and resources to maximize positive outcomes.
Data and resource utilization will include application of rehabilitation principles:
1. Optimizing patient health and maintaining function
2. Communicating with the patient and family regarding quality of life issues
3. Directing long-term recovery and rehabilitation for home, community, and/or institutional settings
4. Applying non-institutional support systems and institutional services for patient and family
VII. FINANCING, UTILIZATION, AND REIMBURSEMENT ISSUES
The resident will be prepared to analyze the continuum of care available to that patient, considering the complex factors inherent to implementation when matching health services to individual needs and resources.
The consideration of factors related to health services will include an analysis of:
1. Elderly patient rights to benefits: age-based and needs-based services and entitlements
2. Delivery of health services available to the patient and his/her family
3. Cost:benefit ratio determination; economic impact of operative procedure
4. Implications of long-term care: the recovery period, quality of life
VIII. PATIENT OUTCOMES