UNIT 7

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Discuss the principles and rationale for performing ambulatory surgery on selected patients, including:

a. Assessment of patient risk

b. Patient selection

c. Level of preparation for patients with co-morbid diseases

2. List those general surgical procedures commonly performed in an ambulatory setting in your community.

3. Discuss the social and economic issues associated with selecting an ambulatory surgery option.

4. Describe the anesthesia options available for ambulatory surgery and their possible complications to include:

a. Discussion of types of anesthetic

b. Delineation of duration of typical local anesthetic action and limitations

c. Calculation of dosages, including maximum dosage of typical local anesthetics

d. Discussion of techniques of local anesthetics, both field and nerve block

e. Consideration of possible adverse reactions

f. Outlining of benefits and risks of pharmacologic sedation

5. Analyze the importance of postoperative pain management in the ambulatory setting.

6. Differentiate between intraoperative issues in awake versus anesthetized patients in terms of:

a. Patient's physical and emotional comfort

(1) Positioning of patient

(2) Patient's physical exposure

(3) Tissue handling

b. Intraoperative communication with the patient

(1) Aspects of procedure

(2) Provide distraction from awareness of procedure via “small talk” or some other means

c. The need to maintain a sensitive and professional level of communication with other health care workers

7. Discuss postoperative follow-up procedures, including methods for monitoring and managing complications.

8. Outline community resources available to assist ambulatory surgery patients, and describe the methods for accessing these resources.

9. Describe appropriate methods for handling pathology specimens for typical outpatient procedures.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

1. Complete a preoperative evaluation of a patient as a potential candidate for ambulatory surgery, including consideration of patient risks and treatment options.

2. Counsel patients and their families appropriately about ambulatory surgery and follow-up care, including obtaining informed consent after discussing the risks, benefits, and alternatives to the procedure.

3. Preoperatively prepare a patient with co-morbid diseases for ambulatory surgery.

4. Perform procedures while assuring patient comfort:

a. Provide adequate local anesthesia and/or adequate sedation

b. Prevent potentially negative visual and auditory stimuli

c. Communicate with the patient intraoperatively in a calm and reassuring manner:

(1) Alert patient to new aspects of the procedure

(2) Communicate results of the procedure to the patient

(3) Respond sensitively to patient's concerns regarding level of pain, embarrassment, and procedure’s results

5. Maintain a positive, calm, reassuring, and professional atmosphere in the operating room.

6. Perform selected ambulatory surgical procedures such as:

a. Excision of skin and soft tissue lesions

b. Breast biopsy

c. Lymph node biopsy

d. Vascular access procedures

e. Incising and draining (I & D) abscesses

f. Endoscopic procedures

g. Hernia repairs

h. Anorectal surgery

i. Laparoscopic cholecystectomy

7. Arrange for appropriate handling of pathological specimens.

8. Manage unexpected emergencies during the course of ambulatory surgery, such as:

a. Hemorrhage d. Chest pain

b. Anaphylactic shock e. Pneumothorax

c. Drug reaction

9. Perform appropriate postoperative examination prior to discharge.

10. Manage postoperative surgery and anesthesia complications.

11. Prescribe necessary follow-up care, including:

a. Prescribing appropriate postoperative analgesia

b. Communicating instructions and expectations for follow-up, such as:

(1) Pain level and location

(2) Possible side effects of medications

(3) Level of activity and return to work

(4) Wound care and potential problems

(5) Timing of follow-up appointment

c. Arrange for home health and other outpatient services using institutional and community resources

Attitudes:

1. Recognize the concerns of patients and family regarding ambulatory surgery and outpatient follow-up care.

2. Become attuned to patient’s concerns and needs:

a. Preoperatively

b. Intraoperatively

c. Postoperatively

COMPETENCY-BASED KNOWLEDGE OBJECTIVES:

1. Delineate the components of and discuss the importance of a focused history and physical examination performed in an outpatient setting on a patient with a surgical disease.

2. Identify indications for, technical aspects of, and typical results from the following screening tests:

a. Stool guaiac c. Prostate screening

b. Sigmoidoscopy d. Mammography

3. Demonstrate a working knowledge of the natural history of surgical diseases:

a. If untreated

b. If treated surgically

c. If treated non-surgically

4. Distinguish between different types of biopsy techniques in an outpatient setting.

5. Specify indications for such common office procedures as:

a. Core-needle biopsy/fine-needle aspiration

b. Incision and drainage of abscesses (recognize those requiring in-hospital operating room drainage)

c. Sigmoidoscopy/anoscopy

d. Excision of cutaneous lesions

6. Delineate hospital mechanisms for admitting patients.

7. Estimate costs of hospitalization and various surgeries.

8. Describe the expected appearance of wound sites at various postoperative intervals.

9. Delineate appropriate pain medications and dosages.

10. Specify the need for drains and tubes, stating the types and special requirements for replacement or removal.

COMPETENCY-BASED PERFORMANCE OBJECTIVES:

1. Demonstrate the ability to obtain the essential elements of a focused preoperative history, including assessment of medications.

2. Perform a complete physical examination, paying special attention to assessment of cardiopulmonary risk of surgery.

3. Order appropriate and cost-effective laboratory tests for screening and pre- and post- operative evaluation.

4. Accurately interpret clinical laboratory results, pathology reports, and radiographic studies.

5. Synthesize historical findings, physical examination, and laboratory data for diagnosis.

6. Develop appropriate plans for management.

7. Order appropriate consultations.

8. Appropriately and sensitively counsel the patient and patient's family regarding:

a. Disease entity (prognosis, treatment options, additional treatment)

b. Surgical issues

(1) Operative risks (possible complications, including mortality)

(2) Operative procedures (preparation, testing, duration of surgery and hospitalization)

(3) Anesthesia

(4) Prognosis (curative vs. palliative)

c. Other treatment options (no treatment [explain natural history of disease] and non-surgical therapy)

d. Informed consent

e. Community resources

9. Perform appropriate office procedures.

10. Arrange patient admission to hospital facility.

11. Explain the prospective surgical approach to the patient.

12. Postoperatively, obtain appropriate follow-up history, including:

a. General well-being

b. Pain control

c. Presence of fever

d. Nutritional state (ability to eat, nausea)

e. Bowel function

f. Level of activity

g. Compliance with instructions (medications, complications of medication, physical therapy)

13. Perform appropriate postoperative examination of the surgical site.

14. Provide appropriate wound care. Identify and manage wound problems, including:

a. Superficial wound separation; abdominal dehiscence

b. Vascular surgery incisions and wounds (diabetic foot problems and their impact)

c. Seromas

d. Infections (cellulitis or abscess, determining the need for antibiotics, drainage, office vs. operating room care)

e. Lymphoceles

f. Incisional hernia

g. Foreign body reaction (to sutures, staples)

15. Ascertain the need for further consultative support, and arrange for patient referral when indicated.

16. Assess the need for further follow-up, including:

a. Arrangement for home nursing evaluation and care

b. Assessment/arrangement for other support (e.g., the homemaker)

c. Prescribing appropriate dietary supplements

d. Hospice care

17. Prescribe appropriate pain medication.

18. Assess patient's ability to maintain level of activity (drive motor vehicle, work, exercise, sexual activity)

19. Appropriately and sensitively communicate with patient and family.

20. Appropriately communicate with referring physicians in a timely fashion regarding patient outcome.

21. Develop the ability to teach in office settings (for nurses, patients, medical students, and junior house officers).

COMPETENCY-BASED ATTITUDINAL OBJECTIVES:

1. Have a working understanding of the role of the surgeon as primary care giver in office and clinical settings.

2. Demonstrate professionalism, empathy, and compassion by showing respect for a patient's privacy and self-esteem during aspects of the physical examination which may be uncomfortable, frightening, or embarrassing for the patient.

3. Demonstrate an awareness of, and respect for, patient autonomy, especially regarding:

a. Decisions about therapy

b. Decisions not to treat

c. Issues of patient compliance

4. Show an awareness of, and respect for, the contributions of other office staff members (nurses, technicians, secretaries).

5. Demonstrate a respect for medical students in office and/or clinic settings.

6. Recognize patient or patient family responsibilities that may affect the timing of surgery.

7. Demonstrate an understanding of, and sensitivity to, patient socioeconomic concerns regarding such issues as:

a. Insurance and the ability to pay for physician services, hospitalization, and prescribed medications

b. Possible loss of work time and wages

8. Demonstrate sensitivity and appropriate flexibility regarding patient fears and concerns, including:

a. Preoperatively

(1) Anxiety about pain and procedure's findings

(2) Embarrassment

b. Intraoperatively

(1) Pain and individual response to pain

(2) Modesty

(3) Comfort

c. Postoperatively

(1) Ability to care for self (3) Level of function

(2) Drugs (4) Prognosis

9. Display a working knowledge of the management of the office and the outpatient surgical setting.

The Management of Ambulatory Surgery and Outpatient Care units were prepared by Michael D. Stone, MD, and Jennifer Doyle, MA.

SELECTED BIBLIOGRAPHY:

Abrams WB, Beers MH, Berkow R. History and physical examination. Comprehensive geriatric assessment. Establishing therapeutic objectives: quality of life issues. Surgery: preoperative evaluation and intraoperative and postoperative care. In: Abrams WB, Beers MH, Berkow R (eds), The Merck Manual of Geriatrics (2^nd ed). Whitehouse Station, NJ: Merck Research Laboratories, Merck & Co., Inc., 1995;205-224; 224-235; 235-238; 321-345.

Annas GJ. Informed consent, cancer, and truth in prognosis. N Engl J Med 1994;330:223-225.

Cobbs EL, Duthie EH, Jr, Murphy JB (eds), Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine (4th ed). Dubuque IA: Kendall/Hunt Publishing Company, 1999.

Dunkle RE, Lynch S. Social work: more of the same or something new? In: Seltzer MM (ed), The Impact of Increased Life Expectancy: Beyond the Gray Horizon, New York, NY: Springer Publishing Company; 1995:131-147.

Friedsam HJ. Long-term care in the very long term. In: Seltzer MM (ed), The Impact of Increased Life Expectancy: Beyond the Gray Horizon, New York, NY: Springer Publishing Company; 1995:165-188.

Howard RJ. Finding the cause of postoperative fever. Postgrad Med J 1989;85:223-238.

Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA 1996;275:152-156.

Macpherson DS, Snow R, Lofgren RP. Preoperative screening: value of previous tests. Ann Int Med 1990;113:969-973.

Moore AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med 1996;100:438.

Narr BJ, Hansen TR, Warner MA. Preoperative laboratory screening in healthy Mayo patients: cost-effective elimination of tests and unchanged outcomes. Mayo Clin Proc 1991;66:155-159.

Powers JS, Billings FT, Jr. Management of perioperative problems in the aged. In: Adkins RB, Jr., Scott HW, Jr. (eds), Surgical Care for the Elderly (2^nd ed). Philadelphia: Lippincott-Raven Publishers, 1998;33-50.

Williams GC, Deci EL. The importance of supporting autonomy in medical education. Ann Intern Med 1998;129:303-308.

Woodard LJ, Pamies RJ. The disclosure of the diagnosis of cancer. Primary Care 1992;19:657-663.

COMPETENCY-BASED KNOWLEDGE OBJECTIVES

1. Differentiate between the following study designs:

a. Descriptive or case‑series

b. Case control (retrospective)

c. Cross‑sectional (prevalence)

d. Cohort (prospective/incidence)

e. Clinical trial

f. Sequential (repeated measures)

g. Crossover

2. Discuss the following concepts related to study design:

a. Internal versus external validity (generalizability)

b. Major threats to internal and external validity

c. Randomization, random selection, random assignment

d. Inclusion versus exclusion criteria

e. Blinding, blocking, stratification

f. Number needed to treat

g. “Intention to Treat” principle

3. Explain the differences between the following scales of measurement:

a. Nominal c. Interval

b. Ordinal d. Ratio

4. Distinguish between the following techniques/methods for exploring and presenting data:

a. Frequency distribution d. Histogram

b. Bar chart e. Frequency polygon

c. Contingency table f. Scatterplot

5. Distinguish between the following statistics used to summarize or describe data:

a. Mean, mode, median

b. Range, standard deviation

c. Percentile, interquartile range

d. Proportion, ratio, rate

6. Interpret the following vital statistics rates:

a. Mortality, morbidity, cause‑specific mortality rates

b. Prevalence, incidence

c. Adjusted rates

7. Distinguish between the following measures of relationship between two variables:

a. Pearson correlation coefficient

b. Coefficient of determination

c. Spearman rank correlation

d. Relative risk, odds ratio

8. Interpret the following terms and concepts related to drawing inferences from research data:

a. Population versus sample

b. Population distribution, sampling distribution, standard normal distribution

c. Standard error versus standard deviation

d. Hypothesis testing, null and alternative (research) hypothesis

e. Parametric versus nonparametric tests

f. Confidence intervals, confidence limits

g. One‑tailed versus two‑tailed tests

h. Level of significance, alpha level, P value

i. Type I error, type II error, power

9. Identify the following tests of significance and concepts related to the comparison of means:

a. Independent and paired t-test (parametric tests)

b. Wilcoxon rank‑sum test (also called the Mann‑Whitney U or the Mann‑Whitney‑Wilcoxon rank‑sum test) (nonparametric test)

c. Wilcoxon signed‑ranks test (nonparametric test)

d. One‑way analysis of variance (ANOVA)

e. Two‑way ANOVA

f. Repeated measures ANOVA

g. Statistical interaction

h. Planned comparisons

i. Posterior or post hoc comparisons such as the Tukey, Scheffe, Newman‑Keuls, Bonferroni, and Dunnett procedures

10. Identify the following tests of significance and concepts related to the comparison of proportions:

a. Z‑approximation test

b. Chi‑square test

c. McNemar test for comparing proportions in paired groups

d. Sample size and strength of association in the interpretation of the chi‑square statistic

e. Fisher's Exact Test

11. Identify the following tests of significance and concepts related to investigating the relationship between two or more variables:

a. t-test for testing the significance of the correlation

b. Fisher's Z transformation

c. Confidence intervals for the relative risk and odds ratio

d. Simple and multiple linear regression

e. Standard error of estimate

f. Confidence bands for a regression line

g. Comparing two regression lines

h. Testing the significance of the regression line and the regression coefficients

i. Stepwise multiple regression

j. Logistic regression

12. Identify the following concepts related to the analysis of survival data:

a. Actuarial or life table analysis versus Kaplan‑Meier

b. Comparing two survival curves using the Gehan or generalized Wilcoxon test, the logrank test, and the Mantel‑Haenszel chi‑square test

c. Censored observations

d. Cox regression

13. Interpret the following concepts related to evaluating diagnostic tests and procedures:

a. Sensitivity and specificity

b. Gold standard

c. Predictive value of a positive or negative test

d. Index of suspicion or prior probability

e. Likelihood ratio method

14. Discuss the following procedures, principles, and concepts related to the ethics of medical research:

a. The Declaration of Helsinki (see Troidl reference)

b. Informed consent

c. Institutional review boards and animal use review committees

d. Ethical use of animals in research

e. Confidentially and anonymity concerns

f. Truth and accuracy in the publication of research results

15. Explain the following procedures and concepts related to clinical databases:

a. Role of clinical databases in clinical research and outcomes research

b. Database terminology such as field, record, query, report generation, ASCII file, computer file, and merging

c. Data coding, data entry, and data verification

d. Use of standardized databases such as hospital tumor registries or state trauma registries

e. Database development

16. Discuss the following principles, methods, and concepts related to evidence-based surgery:

a. Basic skills needed to critically evaluate the published evidence:

(1) Defining the clinical question

(2) Translating the question into searchable keywords

(3) Conducting the search

(4) Selecting the best articles

b. Users’ guides for selecting and evaluating articles about therapy, diagnosis, harm, and prognosis

c. Selection and evaluation of integrative articles such as review articles, meta-analyses, practice guidelines, and decision analyses

d. Use of administrative databases to link patient outcomes to costs related to producing these outcomes

e. Use of patient-reported outcome measures as another method for evaluating the success of surgical treatments

COMPETENCY-BASED PERFORMANCE OBJECTIVES

1. Critically evaluate the published evidence for a surgical therapy using a computer search engine such as MEDLINE, using the users’ guide for evaluating therapy articles, and summarizing your findings in writing, to include your recommendation for surgical practice.

2. Write a summary of the literature review, including a synthesis of the major findings and a recommendation for surgical practice.

3. Develop and implement a computer-based clinical database using a software package such as EXCEL, ACCESS, SPSS, SAS, FileMaker, or other commercially available software.

4. Identify and prepare a case study suitable for presentation or publication.

5. Design and conduct a surgical research study, utilizing the following activities:

a. Select/search for a researchable project, involving an attending or other clinician-mentor

b. Search and review the literature

c. Formulate hypotheses

d. Identify key variables (both predictor and outcome), decide on the optimal level of measurement, create operational definitions, and assess reliability

e. Develop a research design

f. Identify population and study sample

g. Develop sample selection procedures

h. Select or develop measures

i. Develop study protocol and prepare institutional review board (IRB) proposal

j. Collect and analyze data

k. Interpret results

l. Identify various journal formats and related instructions to authors

m. Write paper

n. Review techniques for optimal presentation of papers and posters, including related media

o. Convert paper into an appropriate presentation

p. Deliver the presentation

The Research and Biostatistical Methods unit was revised by Melvin S. Swanson, PhD, from the Curriculum, third edition.

SELECTED BIBLIOGRAPHY:

Black J, Troidl H, et al. Surgical Research (3^rd ed). New York: Springer-Verlag, Inc., 1997.

Davis AT. Biostatistics. In: O’Leary JP, Capote LR (eds), The Physiologic Basis of Surgery (3rd ed). Philadelphia: Lippincott Williams and Wilkins, 2002.

Dawson B, Trapp RG. Basic and Clinical Biostatistics (3rd ed). New York: McGraw-Hill, 2000.

Glaser AN. High-Yield Biostatistics (2^nd ed).Philadelphia: Lippincott Williams & Wilkins, 2001.

Gordon T, Cameron JL. Evidence-Based Surgery. Hamilton, Ontario: BC Decker, Inc., Publisher, 2000.

Hulley S, Cummings S, et al. Designing Clinical Research: An Epidemiologic Approach (2^nd ed). Philadelphia: Lippincott Williams & Wilkins, 2000.

Huth EJ. Writing and Publishing in Medicine (3rd ed). Philadelphia: Lippincott Williams & Wilkins, 1998.

Kahn JP, Mastroianni AC, Sugarman J. Beyond Consent: Seeking Justice in Research. New York: Oxford University Press, 1998.