Standardized Curriculum in General Surgery 2012

1

MESSAGE PSGS President 2006

Fully aware of the rapid expansion of new knowledge and new surgical techniques that affect our training programs, the Committee on Surgical Training embarked on the challenging task of revising our surgical curriculum. As we remain committed to maintain an excellent General Surgery training program that keeps abreast with the ongoing developments and progress in the practice of surgery, we have remained sensitive to the limitations that affect each and every training program, allowing enough opportunity for gradual adaptation before the full implementation of this revised curriculum. We have always prided our society by ensuring that all accredited training programs under its watch will produce excellent clinical General Surgeons who are able to go out and practice with confidence in any situation, both in ideal and not so ideal set up, and still adhere to the tenets of sound surgical practice. In order to achieve our goals, we have finally developed a strong and updated surgical curriculum that would adequately arm our trainees with a comprehensive surgical educational experience during their entire period of residency training. I would like to express my sincerest thanks and gratitude to the members of the surgical training committee, for their dedication, and to all who have in one way or another participated, provided inputs and ideas; and for the comments and suggestions, and full support of all the Fellows that led to the formulation of our new surgical curriculum. I look forward to the continued success in its eventual implementation. Arturo E. Mendoza, Jr., MD, FPSGS President, 2006

2


Through the years, the Curriculum in General Surgery has evolved from its first edition in 1995 to the present competency-based, resident-oriented educational curriculum. This 3rd edition, which underwent extensive review, is the fruit of all efforts, shed through sweat and tears, of the Committee on Surgical Training of the PSGS. We can now confidently claim that this manual is truly reflective of our expectations from the graduates of the training program and this will significantly help produce competent and sage general surgeons. Henceforth, this curriculum will now serve as the foundation, upon which the new Accreditation Manual shall be made, which in turn shall take effect after the year 2007. With the completion of these two vital documents, we will then see the fulfillment of an important aspect of our Societys Vision-Mission. It is fitting to express my heartfelt gratitude to all who contributed in making this document something we can truly be proud of and something that will be relevant in the years to come. Reynaldo M. Baclig, MD, FPSGS President PSGS 2007

3


4

Preface to the 1st Edition

One of the tasks assigned to the Committee on Surgical Training was the improvement of the Surgical Curriculum. Towards this goal, the 1991 Surgical Curriculum was re-oriented into a competency-based, resident-oriented educational curriculum. An educational curriculum contains the following basic elements (from Hilda Taba Curriculum Development: Theory and Practice):

Objectives Content (subject matter) Teaching-Learning activities Evaluation

To make it applicable to surgical residency programs, we have added the competencies or abilities that residents need to develop, the organization of rotations in a four- or five-year program, and the resources needed for training. We have also formulated an Instructional Design that contains the basic elements. This pattern should be used in designing various units of instruction (ex. trauma, burns, cancer, etc.) The last part contains the Standardized Evaluation System for Residents, with the rating scales developed to evaluate different competencies. A definition of terms used in the curriculum and evaluation follows thereafter. We certainly encourage all trainors to utilize this as the basic guide in teaching and evaluating residents in training. We recognize the critical role that trainors play in residency training. The quality of our graduates is directly related to the dedication and commitment of the trainors, and to how well the curriculum is implemented. Trauma, cancer and infections are national health concerns that should be emphasized. We want trainees to be fully aware of the goals and objectives of the training program and the competencies that they need to develop. Hopefully, this will motivate them to work hard towards the attainment of the objectives, and acquisition of necessary competencies. I would like to acknowledge the contributions of the members of the Board of Regents, Committee on Surgical Training, Committee on Accreditation, and the Chairmen and Training Officers of the different institutions. I would like to give credit to Dr. Armand Crisostomo for his efforts in the formulation of the Standardized Evaluation System for Residents. Lastly, I would like to thank Dr. Tarlochan Kaur Pabla Gailan of the UP- National Teacher Training Center of the Heath Professions for her critique and suggestions for improving the draft of the Surgical Curriculum and Instructional Design.

JOSE Y. CUETO, Jr., MD, FPCS Chairman

PCS Committee on Surgical Training, 1995

5

Preface to the 2nd

Edition This edition of the Surgical Curriculum and the Evaluation System arose out of a need to address concerns raised by Trainers in general surgery and the surgical specialties. It is also the result of feedbacks from the Residents in training. In 1998, Drs. Josefina Almonte and Armand Crisostomo in cooperation with the PCS Committee on Surgical Training (CST) and the Philippine Association of Training Officers in Surgery (PATOS), conducted a survey on the Implementation of the Standardized Curriculum and the Utilization of the PCS Standardized Evaluation System respectively. The results of these surveys revealed the following:

1. The need to review the standardized surgical curriculum pertaining to the specialty rotations to find out how the different programs can comply with the requirements of the PCS.

2. The necessity for the various training programs to conduct a self-evaluation of their

program components i.e. objectives, products and resources.

3. Nearly all training programs agreed with the specific criteria utilized in the prescribed rating scales and the number of anchor points in the evaluation system.

4. Despite its being assessed as valid, reliable, and useful, some programs found the

evaluation system difficult to implement due to inherent weaknesses in their programs (lack of dedicated trainers/evaluators, poor quality of residents, poor structure of the program, etc.).

In May of 1999, the PATOS conducted a Workshop on Program Evaluation for trainers in Subic. On October 30, 1999, the CST met with representatives from the surgical specialties for a multidisciplinary workshop to identify the minimum competencies of a general surgery resident rotating in the specialties and to improve the Standardized Surgical Curriculum and Evaluation System. The outputs of the surveys and workshops were consolidated by the CST and incorporated into this edition of the Surgical Curriculum for General Surgery.

GABRIEL L. MARTINEZ, MD, FPCS Chairman

PCS Committee on Surgical Training, 2000

6

Preface to the 3rd

Edition

The birth of the PSGS in 1999 and its subsequent assumption of the accreditation functions from the PCS in 2002, paved the way for the eventual handover of the PCS Curriculum in General Surgery to the PSGS. Realizing the need to keep pace with the rapid developments in surgical education, knowledge and technology, the 2005 PSGS Board of Directors (BOD) directed the PSGS Committee on Surgical Training (CST) to initiate the revision of the General Surgery curriculum. In September 2005, the PSGS-CST constituted itself into a Technical Working Group (TWG) to identify areas that needed revision or improvement. Utilizing the existing curriculum as a template, coupled with data from the various accredited training programs and the Philippine Board of Surgery (PBS), a working model was presented to an expert panel for critique and revision on July 5, 2006. The panel consisted of members of the PSGS BOD, PSGS Accreditation Committee (AC), PSGS-CST and the Philippine Association of Training Officers in Surgery (PATOS). This activity produced the Intended Learning Outcome (ILO) version of the curriculum. On August 5, 2006, during the PSGS 4th Annual Surgical Forum, the ILO-based curriculum, a work in progress, was presented to the trainers representing the various training programs for suggestions, revisions and comments. The trainers were given time to consult their training programs and other stakeholders. On October 14, 2006, after collating all available data, comments and suggestions from the stakeholders, the PSGS-CST conducted a Workshop at the PCS Board Room to finalize the Surgical Curriculum. In attendance were representatives from the various training programs, PATOS, PSGS BOD, members of the PSGS Committee on Accreditation and PSGS-CST. Resource persons who also acted as Facilitators were: Drs. Josefina R. Almonte, Armando C. Crisostomo and Jose Y. Cueto, Jr. Taking into consideration the existing realities and the Social Responsibility role of the PSGS, revisions were made and incorporated into the final draft of this document. On December 3, 2006, the final draft of the Surgical Curriculum was presented to the trainers and stakeholders for ratification and adoption. With very minimal revisions in form, style and content, this edition of the Surgical Curriculum was born. I would like to thank the members of the Committee on Surgical Training, notably Dr. Shirard Leonardo C. Adiviso, our advisers and resource persons, trainers and stakeholders for their invaluable contribution and service towards the success of this endeavor.

GABRIEL L. MARTINEZ, MD, FPCS, FPSGS

Chairman PSGS Committee on Surgical Training, 2005-2007

7

Preface to the 4th Edition

The opportunities of our PSGS Fellows for foreign trainings in others countries like the US, Europe, India, Singapore and Vietnam and the available expertise in the Medical Health Profession Education and Healthcare Management greatly provided support in formulating revisions in this new curriculum. The globalization of healthcare and the focus in Patient Safety worldwide also guided the committee to address not only the improvements in cognitive and psychomotor skills needs of our learners as stated in Blooms Taxonomy of Learning but we also strengthened in the Values Formation. The goals of training is focused in developing Safe, Competent and Ethical surgeons with basic clinical teaching abilities,knowledge in academic and clinical research and with good leadership and managerial skills. The curriculum is now divided in three broad topics namely Medical Knowledge, Patient Care and Professional Growth. We updated the medical knowledge parts and integrated new concepts, practice guidelines and advancement in surgical technology. The patient care part is upgraded and updated based on globally accepted practice. We added topics in professional growth to enhance value formation to this future leader and managers of our society and most of all to make them good role models for the next generations of trainees. The new curriculum includes the following: 1) Clinical Nutrition 2) Clinical Teaching 3) Patient Safety 4) Professionalism 5) Leadership & Management The course content has also been updated based on recent global trends in health care. The part of Minimal Invasive Surgery has been greatly enhanced based on standards of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and European Association for Endoscopic Surgery (EAES). The updates for MIS training had been collaboratively established with representatives from Philippine Association of Laparoscopic and Endoscopic Surgeons (PALES). The proposed revised curriculum was again presented in the PSGS Forum last August 6, 2011 for final comments and ratification. We would like to extend our appreciation to the pioneer PSGS CST chairman, Dr Gabriel Martinez who sent several comments and recommendations for the improvement of the curriculum. We would like to extend also our warmest gratitude to the guidance and support of the PSGS Board most especially our president, Dr. Ervin Nucum and our Director in charge, Dr Rex Madrigal in pursuing this endeavor. We would like to thank the generosity of B. Braun Medical Supplies through its continuing education arm, Aesculap Academy for its never ending support to the Committee on Surgical Training since we started with the 3rd edition last 2005 until today. We also would like to give credit to Dr. Luisito Llido, one of the pioneers of Surgical

8

Nutrition in our country for sharing his expertise not only in the curriculum but also to the training modules in this area. Finally, I would like to send my deepest gratitude to the Committee on Surgical Training members most especially to Drs. Malen Gellido, Deo Reyes, Warren Roraldo and Michael James Busa who sacrificed their time and talents in attending almost all the meetings and fulfilling their respective tasks and assignments in this revision. You are a distinguished league of selfless and dedicated surgical educators and it is my great pleasure working with you. SHIRARD LEONARDO C. ADIVISO MD,MHPEd ,FPCS,FPSGS Chairman, Committee on Surgical Training, 2011

9

Dedication

This Manual is dedicated to our mentors who with their unselfish guidance ushered us to become the trainers and educators they wanted us to be; To the trainers and training residents in General Surgery, may their pursuit of continuing surgical education and quality surgical care endure and prevail over the challenges of the changing times; To the unsung and unappreciated heroes of the surgical profession, may they furnish the inspiration for future generations of surgeons; And to the future generations of General Surgeons, may you continue and uphold the ideals of the surgical profession and produce ethical, safe, and compassionate surgeons.

ACKNOWLEDGEMENTS

To the members of the PSGS Board of Directors 2006 & 2007 for their support towards the realization of this endeavor; to the Committee on Surgical Training 2005-2007 for their tireless efforts and perseverance; to Drs. Armando C. Crisostomo, Jose Y. Cueto, Jr. and Josefina R. Almonte who whole-heartedly collaborated with the Committee on Surgical Training to complete this edition of the Standardized Surgical Curriculum; to the countless resource persons and participants in the various workshops for their feedbacks and critiques; to our friends in the pharmaceutical industry for their logistical and material support; and most importantly the PSGS Secretariat, especially Ms. Angela Panlaqui, for their patience and perseverance despite the odds.

10

TABLE OF CONTENTS Message of PSGS President 2006 1 Message of PSGS President 2007 2 Message of PSGS President 2011 3 Preface to the 1st Edition 4 Preface to the 2nd Edition 5 Preface to the 3rd Edition 6 Preface to the 4th Edition 7 Dedication and Acknowledgements 9

Part I

I. Introduction 11 II. The Mission and Vision of the PSGS 13 III. The Surgical Curriculum 14 IV. Concept map of goals of training 15 V. Goal of the Training Program 15 VI. The General Objective of the Training Program 15 VII. The Competencies 16 VIII. Levels of Training 16 IX. Intended Learning Outcomes 16 X. The Course Content 19 XI. Teaching-Learning Activities 31 XII. Organization of Rotations 32 XIII. The Resources 33 XIV. Evaluation 34

Part II

The Instructional Design for the Surgical Curriculum 35

Part III The Evaluation System for Residents 48 Appendices 52 Instructional Designs for Specialty Rotations 68 Glossary 96

11

PART I

I. INTRODUCTION

In 1991, the Philippine College of Surgeons, under Dr. Willie Lagdameo, formulated the standardized surgical curriculum in two workshops. These workshops were participated in by representatives of the Philippine College of Surgeons, Philippine Board of Surgery, Chairmen and Training Officers, Chief Residents of different training institutions. These were subsequently followed by a number of workshops addressing topics related to the provisions of the surgical curriculum. 1. Workshop on Accreditation at the Johnson & Johnson Compound, Paraaque, Rizal

2. Workshop on Competencies at the Manila Garden Hotel

3. Workshop on Standardized Evaluation, in Manila at Glaxo, Philippines, Pasong

Tamo Extension, Makati City and in Cebu City at the Cebu Midtown Hotel

4. Mini-workshop on Accreditation at the Johnson & Johnson Compound in Paraaque, Rizal

In the last workshop, problems in the interpretation of provisions of the surgical curriculum and the requirements for accreditation were identified. In addition, a survey of the descriptions of training programs was conducted to determine whether standardization has been attained. The survey showed that, three years after the workshop on the standardized curriculum, there was still lack of standardization of the surgical curricula being followed by different institutions. The PCS Committee on Surgical Training formed a Technical Sub-Committee to come up with proposals to improve the curriculum. Essentially, what was done was to convert the 1991 Surgical Curriculum into a Competency-based Surgical Curriculum. The proposed Surgical Curriculum was then presented, discussed, modified and finalized in a workshop held at the PCS on November 19, 1994.

In 1995, the PCS started implementing the Standardized Surgical Curriculum in General Surgery and Evaluation System for Residents. Three years later, in 1998, Dr. Josefina R. Almonte presented the results of her survey on the Implementation of the Surgical Curriculum while Dr. Armando C. Crisostomo presented the results of his survey on the Utilization of the PCS Standardized Evaluation System.

The results of these surveys prompted the PCS Committee on Surgical Training to conduct a workshop on October 30, 1999, to improve the Surgical Curriculum and Evaluation System and to identify the competencies of the general surgery resident rotating in the other surgical specialties. The outputs of the surveys and the workshops were processed and incorporated into the 2nd edition of the Surgical Curriculum.

12

Upon the formation of the Philippine Society of General Surgeons (PSGS) in 1999, the PCS handed over to it the task of accrediting general surgery programs and with that the 1995 Manual on Requirements and Procedures for Accreditation in General Surgery. Thereafter, the PSGS embarked on the task of revising the Accreditation Manual. After a series of workshops and consultations with stakeholders, the PSGS Manual on Requirements and Procedures for Accreditation in General Surgery saw print. Implementation began in 2004.

In August 2005, in response to the rapid growth in surgical education, technology and the general surgical subspecialties, and the need to achieve uniformity in the implementation, structure and duration of the training programs, the PSGS Board of Directors tasked the Committee on Surgical Training to lay down the ground work for the eventual revision of the Surgical Curriculum.

In September 2005, the PSGS-CST constituted itself as a Technical Working Group (TWG) to revise the curriculum. Annual reports were reviewed, trainers were interviewed and data provided by the Philippine Board of Surgery (PBS) were considered.

Data gathered revealed that thirty (30) of the 64 training programs are in government hospitals. Due to some legal impediments, 15 of them are implementing the 4-year curriculum; the remaining 49 programs are implementing the 5-year curriculum. The absence of uniformity in specialty rotations and teaching-learning activities, coupled with the lack of dedicated trainers/evaluators, due to the brain drain, have strained the ability of some programs in maintaining the quality of their training. The average passing in the PBS Residency In-Training Examination is 69.4%; in the Written Examination it is 68.1% and in the Oral Examinations it is 51.0%. The PBS Credentials Committee reports deficiencies in variety of cases and in some cases, lack of trainer supervision.

In July 2006, in a workshop attended by the PSGS BOD, members of the Committee on Accreditation and the CST, the TWG submitted an Intended Learning Outcome (ILO) based Preliminary Report. The product of this workshop was presented to the trainers in August 2006. The same was given as a take home model for the trainers to critique, to comment on and revise. Feedback sent via surface and electronic mails were incorporated into a working model of the curriculum.

On October 14, 2006, another workshop attended by the PSGS BOD, members of the Accreditation Committee, the CST and representatives of the various training programs, was held at the PCS Building

On December 3, 2006, the final draft of the Surgical Curriculum, with very minimal revisions in form and content, was adopted and approved by the body.

13

II. THE MISSION AND VISION OF THE PHILIPPINE SOCIETY OF GENERAL SURGEONS

Mission

We are a Fellowship of highly competent, safe, compassionate, and ethical surgeons dedicated to pursue excellence in the art and science of General Surgery

as a distinct specialty, promote the welfare of its members, uphold the highest standards of practice, and provide quality care to all surgical patients.

Vision

The Philippine Society of General Surgeons is the premier organization of General Surgeons, highly esteemed and recognized for their pioneering achievements in continuing surgical education, training, and research, dedicated to promote the welfare of its members, to provide compassionate and quality health care, and

responsive to the needs of the community.

14

III. THE SURGICAL CURRICULUM A. The Surgical Curriculum: What it is

As an educational document, the surgical curriculum serves as the written plan of action for residency training. It contains the program of studies, the course content, the planned learning experiences and the intended learning outcomes. It identifies the resources needed for the program, and provides a system for assessing the performance and the competence of residents.

B. The Elements

1. Statement of goals and objectives 2. Identification of competencies or abilities 3. Selection and organization of content 4. Teaching-learning activities and methods 5. Organization of Rotations 6. The learning resources 7. Evaluation

15

ELEMENTS OF THE SURGICAL CURRICULUM

A. Concept Map of PSGS Goals of Training

B. GOAL OF THE TRAINING PROGRAM

To train Residents in General Surgery to assume the following roles: 1. Primarily as CLINICIANS or MEDICAL PRACTITIONERS providing ethical , safe, and

competent patient care to individuals with surgical disorders in different settings such as the community, the hospital, schools and different institution .This is focused on principles of evidence based practice, patient safety, professionalism and collaborative quality patient care.

It is desirable to prepare the Residents for the following roles:

2. As clinical and academic RESEARCHERS involved in the study of current and

relevant issues related to the practice of Medicine in general. 3. As MEDICAL EDUCATORS involved in teaching and training of students in Medicine

and other health professions. He will be exposed to the following roles of the teacher namely: Information provider, facilitator, planner, role model, resource developer and assessor.

4. As ADMINISTRATORS with excellent managerial and leadership skills involved in

managing and organizing the activities of institutions, organizations or departments of the hospital.

C. THE GENERAL OBJECTIVE OF THE TRAINING PROGRAM

At the end of the Residency Training, the Graduate should have acquired clinical competence in the diagnosis and management of surgical disorders.

16

D. The COMPETENCIES these are the ABILITIES that Residents in all levels of training have to acquire and develop.

1. COGNITIVE DOMAIN

Knowledge Comprehension Intellectual Skills Data-gathering Analysis Problem-solving Decision-making Critical thinking

2. PSYCHOMOTOR DOMAIN Technical Skills

Communication Skills 3. AFFECTIVE DOMAIN

Interpersonal Skills Professionalism

E. LEVELS OF TRAINING

Levels of Training

Level I Junior Year First Year Level II Intermediate Years: Second Year Third Year Level III Senior Years: Fourth Year Fifth Year

F. INTENDED LEARNING OUTCOMES A. At the end of the JUNIOR YEAR, the RESIDENT should be able to:

1. COGNITIVE DOMAIN 1.1. Apply the principles of diagnosis and management of common general

surgical disorders. 1.2. Evaluate patients with surgical disorders

a. Obtain an adequate history b. Perform a thorough physical exam c. Order pertinent laboratory and diagnostic exams

17

d. Formulate a logical diagnosis e. Formulate treatment plan f. Refer appropriately g. Provide continuing care

2. PSYCHOMOTOR DOMAIN

2.1. Perform minor surgical procedures 2.2. Assist in the performance of surgical procedures done by consultants

and other residents

3. AFFECTIVE DOMAIN

3.1. Demonstrate the proper attitudes and habits in the practice of surgery. 3.2. Accept own limitations

B. At the end of the INTERMEDIATE YEARS (second and third years), the RESIDENT

should be able to:

1. COGNITIVE DOMAIN

1.1. Apply the principles of diagnosis and management of GS and surgical specialty disorders

1.2. Evaluate and manage patients a. Obtain an adequate history b. Perform a thorough physical exam c. Order pertinent laboratory and diagnostic exams d. Formulate a logical diagnosis e. Formulate treatment plan f. Implement treatment plan g. Refer appropriately h. Provide continuing care

2. PSYCHOMOTOR DOMAIN 2.1. Perform or assist in the performance of surgical procedures

3. AFFECTIVE DOMAIN 3.1. Demonstrate the proper attitudes and habits in the practice of surgery 3.2. Accept own limitations

C. At the end of the SENIOR YEAR, (fourth and fifth years) the Graduate should be able to:

1. COGNITIVE DOMAIN

1.1. Apply the principles of diagnosis and management of GS and surgical specialty disorders

18

1.2. Provide pre-operative, intra-operative and post-operative care to all patients falling under all fields of surgery

2. PSYCHOMOTOR DOMAIN

2.1. Perform or assist in the performance of surgical procedures

3. AFFECTIVE DOMAIN 3.1. Demonstrate the proper attitudes and habits in the practice of Surgery 3.2. Accept own limitations

19

G. THE COURSE CONTENT

This deals with the subject matter that the residents have to learn. Traditionally, the course content has been divided into basic and clinical topics. This follows the sequence of simple to complex, basic to clinical. There is cumulative learning as one goes from the earlier years to later years. Basic pre-requisites are mastered before more complicated topics and tasks are tackled. The residents have to acquire knowledge and comprehension of facts, concepts, principles, and theories before they can apply them. The application and integration of basic concepts and principles into actual clinical practice are the main goals. It follows that the residents are expected to master the common surgical problems and disorders that they will encounter in their future role as Surgeons.

20

A. BASIC SURGERY

1. FLUIDS AND ELECTROLYTES a. Normal composition of body fluids b. Fluid and electrolyte imbalance

Volume deficit and excess Concentration changes

c. Acid base imbalance Respiratory acidosis/alkalosis Metabolic acidosis/alkalosis

d. Principles of fluid and electrolyte therapy Parenteral solutions Preoperative fluid therapy Intraoperative and Postoperative fluid therapy

2. SHOCK & RESUSCITATION

a. Definition b. Pathophysiology c. Types of shock d. Treatment

3. SURGICAL NUTRITION

a. Nutrition risk assessment Subjective Global Assessment

b. Nutritional Intervention Oral feeding Enteral feeding Parenteral feeding

c. Complications related to Nutritional support d. Nutritional Immunomodulation

4. ENDOCRINE AND METABOLIC RESPONSE TO INJURY

a. Central nervous system and endocrine changes b. Metabolic changes

Energy, CHO, fat and protein-metabolism Starvation Metabolic effects of injury Blood coagulation

c. Acid-base balance, water and electrolyte metabolism d. Oxygen transport e. Organ system changes

5. WOUND HEALING a. Physiology of wound healing

Phases of wound healing b. Factors affecting healing c. Wound care d. Wound closure

21

6 BLEEDING AND BLOOD TRANSFUSION a. Biology of normal hemostasis b. Blood coagulation

Intrinsic pathway Extrinsic pathway Fibrinolytic system

c. Clinical tests for hemostasis d. Clinical defects in hemostasis -manifestations and treatment e. Blood transfusion

Replacement/Component therapy Indications Complications

7. BURNS

a. Classification according to extent & depth b. Systemic changes c. Therapy

Airway Fluid resuscitation, Rule of Nines, Brookes and Parkland formulae Burn wound care, skin grafting Complications

8. SURGICAL ONCOLOGY

a. Molecular Biology and Oncogenesis a. Pathology b. Clinical Manifestations of Cancer c. Diagnosis and Staging d. Multidisciplinary management options

Surgery Radiotherapy Chemotherapy Immunotherapy Targeted therapy Hormonal therapy

e. Prognosis f. Long-term care and follow-up

9. TRAUMA a. Epidemiology, Patterns of injury and Prevention b. Basic Life Support and Triage c. Principles of Management

Primary Survey Resuscitation Secondary Survey Definitive Management

22

d. Management of Specific Injuries Head Neck Chest Abdomen Extremities Others

e. Approach to the multiply injured patient f. Care of the critically ill trauma patient g. Rehabilitation e. Mass casualty and disaster management

10. CRITICAL CARE a. Physiologic Monitoring b. Specific Conditions

SIRS Sepsis MODS MOF

ARDS DIC

c. Vascular Access Peripheral

Central d. Metabolic Support

11. SURGICAL INFECTION

a. Sepsis, Asepsis and Antisepsis b. General Principles of Diagnosis, Antibiotic and Surgical Therapy c. Antibacterial / Antifungal /Anti-Viral Drugs: Classification,

Principles, Therapy d. Specific Infections

Streptococcal Staphylococcal Gram negative infections Anaerobic infection Fungal infections AIDS Viral Hepatitis

e. Surgical Aspects of Treatment 12. PRINCIPLES OF IMMUNOLOGY AND TRANSPLANTATION

a. Immunosuppression b. Clinical Tissue and Organ Transplantation c. Organ Preservation

23

13. SURGICAL COMPLICATIONS a. Recognition b. Diagnosis c. Management

14. MINIMALLY INVASIVE SURGERY a. Principles of MIS Physiologic response to Pneumoperitoneum

b. Equipment c. Energy sources

Electrosurgical safety d. Operating room set-up e. Ergonomics and Instrumentation f. Basic Skills Looping Clipping Ligation In-continuity Endo-dissection Extra/Intra-corporeal tying Endo-suturing g. Basic Laparoscopic procedures Diagnostic Laparoscopy Laparoscopic Cholecystectomy Laparoscopic Appendectomy 15. PERIOPERATIVE CARE a. Patient preparation b. Co-morbidities and risk assessment c. Pain control 16. PATIENT SAFETY AND PROFESSIONALISM

B. CLINICAL SURGERY-GENERAL SURGERY

1. HEAD AND NECK

a. Anatomy and Physiology b. Clinical Presentation c. Diagnostics d. Specific Condition

Congenital Masses Thyroglossal cysts Teratomas Branchial clefts Vascular tumors Hygromas

24

Noncongenital lesions Papillomas Polyps Dermoid tumors Rhabdomyomas and Neurofibromas Chemodectomas

Malignancy General Principles epidemiology, risk factors, clinical work-up, therapeutic considerations Neck cancer

- triangles of the neck - staging TNM - surgical treatment- radical neck dissection

Nasal Cavity and Paranasal sinuses Nasopharynx Oropharynx Salivary Glands

e. Treatment f. Follow up

2. THE THYROID AND PARATHYROID GLANDS

a. Anatomy and Physiology b. Clinical Presentation c. Diagnostics d. Specific Conditions

Hyperthyroidism/hypothyroidism Thyroid neoplasms

Papillary Follicular

Medullary Anaplastic cancers

Hyperparathyroidism / hypoparathyroidism Parathyroid neoplasms


3. THE BREAST


Benign Cystic changes Breast infections

Fibroadenoma Ductal papilloma

25

Gynecomastia Galactocoele Malignant Ductal carcinoma In situ Invasive Lobular carcinoma In situ Invasive Special types of carcinoma Sarcoma Phyllodes Tumor Congenital


4. Skin and Soft Tissue Tumors


Benign

Malignant e. Treatment f. Follow up

5. ABDOMINAL WALL DEFECTS AND HERNIAS


Umbilical Indirect inguinal Direct inguinal Femoral Sliding Ventral

Incisional Others

e. Treatment Open Tissue Repair Open Mesh Repair Laparoscopic Approach

TAPP TEP

26

f. Follow up

6. THE ESOPHAGUS


Motility disturbances Diverticulae Esophageal Strictures (Benign) Esophageal Perforation Esophageal varices Malignant Tumors

Adenocarcinoma Squamous Cell Others


7. THE STOMACH AND DUODENUM


Peptic Ulcer Disease and its Complications Gastric varices Gastric Malignancies Morbid Obesity


8. THE SMALL-INTESTINE, COLON, RECTUM AND ANUS

a. Anatomy and Physiology b. Clinical Presentation c. Diagnostics d. Specific conditions

Polyps Intestinal Obstruction Intestinal Tuberculosis Amoebic Colitis Typhoid Enteritis Diverticular Disease Crohns disease & ulcerative colitis

Volvulus

27

Rectal Prolapse Intussusception Malignant conditions of the small intestines Surgical lesions of the appendix appendicitis, etc. Short Bowel Syndrome Colonic malignancies Rectal Malignancies Hemorrhoids, Abscesses and Fistula-in-ano Anal Carcinoma Condyloma Acuminata Trauma Others


9. THE LIVER, GALLBLADDER AND BILIARY TREE

a. Anatomy and physiology b. Clinical Presentation c. Diagnostics d. Specific Conditions

Liver abscesses Liver Cysts Benign hepatic tumors Primary and metastatic cancer of the liver Portal Hypertension Gallstones Acute and chronic cholecystitis Cholangitis Cholangiocarcinomas Choledochal cysts

Trauma Others


10. THE PANCREAS & SPLEEN


Pancreatitis Cysts & Pseudocysts Pancreatic tumors Hypersplenism Trauma

28


11. ACUTE SURGICAL ABDOMEN

a. Definition b. Clinical manifestations c. Conditions which may mimic or give rise to acute surgical

abdomen d. Approach to patients with suspected acute surgical abdomen e. Principles of surgical management

C. CLINICAL SURGERY SUBSPECIALTY SURGERY Objective: At the end of the specialty rotations, the resident should be able to recognize and institute initial management for common and life or limb-threatening specialty problems.

1. PEDIATRIC SURGERY

a. Perioperative Care b. Common Pediatric Surgical Conditions

Acute Abdomen Appendicitis, GI bleeding, Obstruction in older children Inguino-Scrotal Problems Neonatal Surgical Emergencies Imperforate Anus, Intestinal obstruction, abdominal wall defects, TEF, Diaphragmatic hernia

c. Congenital Masses - Thyroglossal cysts, Teratomas, Branchial clefts, vascular tumors, Hygromas

2. PLASTIC SURGERY

a. Technical considerations in skin grafts & flaps b. Management of maxillofacial trauma c. Congenital anomalies

Cleft lip and palate d. Cosmetic surgery Principles

Scar revision Rhinoplasty Blepharoplasty Mammoplasty

3. UROLOGY

a. Anatomy and Physiology of GUT b. Diagnosis c. Disease Conditions and Treatment

29

Urinary calculi Tumors Renal, Bladder, Prostatic, Testicular Urologic Trauma Other Urologic Emergencies - Anuria due to obstructive uropathy, bilateral, outlet obstruction including neurogenic bladder - Acute scrotum (testicular torsion)

4. ORTHOPEDICS

a. Orthopedic Trauma Fractures Common long bone fractures Hand injuries

b. Orthopedic infection Septic arthritis, osteomyelitis, Potts Disease

c. Bone and Soft tissue neoplasms of the extremities d. Congenital orthopedic deformities, Scoliosis e. Diagnostic: FNAB, Superficial joint aspiration (elbow and

knee) f. Technical considerations: casting, splinting, traction

techniques

5. THORACIC AND CARDIOVASCULAR SURGERY

a. Anatomy and Physiology of the Heart & Lungs b. Common Surgical Conditions

Trauma Peripheral Vascular injury Diaphragmatic injury

c. Neoplasms Lung primary and metastatic Metastatic Mediastinal tumors d. Infections Empyema thoracis e. Common Vascular conditions Peripheral vascular occlusive disease Varicose veins Abdominal aortic aneurysm f. Common Cardiac Conditions Pericardial effusion

6. NEUROSURGERY a. Anatomy and Physiology of the CNS b. Common surgical conditions

30

Recognition and initial management of increased ICP- trauma, space-occupying lesions Trauma low velocity gun shot wounds

c. Indications for use and interpretation of diagnostic tests-skull x-ray, CT, angiogram

D. PRINCIPLES OF SURGICAL DIAGNOSTICS: 1. Laboratory work ups

Blood Chemistry Immunohistochemistry Tumor Markers Others

2. Imaging Studies X-ray Ultrasound CT scan MRI PET scan Nuclear Scintigraphy

3. Endoscopy 4. Laparoscopy 5. Biopsy

31

H. TEACHING-LEARNING ACTIVITIES

To achieve the wide range of training objectives-cognitive, psychomotor, affective; the program has to provide relevant learning experiences. The activities should focus on the development of higher cognitive-skills like problem-solving and decision-making. Technical skills should be refined appropriate to the level of training. The proper attitudes and values needed in the practice of Surgery should be enhanced. The competencies and abilities acquired by the residents should be demonstrated in how patients are managed, how procedures are performed, and how cases are presented and discussed. 1. Patient Management

Patient Care in the hospital setting Wards & Emergency Room Operating Room & Recovery Room Intensive Care Unit Outpatient Clinics Community Service & Surgical Missions

2. Presentation and Discussion in the classroom setting Pre-and post-op Conference Mortality/Morbidity Conference Journal Club Didactic lectures Multidisciplinary Conferences Ward rounds Grand Rounds Interdisciplinary Tumor Conferences

3. Skills Acquisition and Demonstration in the Hospital Setting Skills Laboratory Operating Room Emergency Room Intensive Care Facilities Outpatient Clinics Wards

32

I. ORGANIZATION & SEQUENCE OF ROTATIONS

The guiding principle: There must be a definite structure and sequence in the organization of rotations: Training programs must be five (5) years or sixty (60) months in duration; at least forty-five (45) months will be spent in General Surgery (GS) and fifteen (15) months will be spent in the other specialties.

General Surgery will include: Surgery for Trauma, Critical Care & Nutrition, Out-patient

Clinics, Emergency Room, Surgical Oncology, and Minimal Access Surgery Specialty Surgery will include: Neurosurgery, Urology, Plastic and Reconstructive

Surgery, Pediatric Surgery, Orthopedic Surgery and TCVS. The length of the rotations will be guided by an Instructional Design for that particular

rotation. The rotations may be combined & interchanged but these must be limited to the Residency Levels indicated.

Conferences in Surgical Pathology and Radiology & Other Imaging Modalities are to be

conducted in lieu of rotations in these specialties. There will be three (3) Residency Levels of Training: Junior, Intermediate and Senior

Level.

The rotations will be as follows:

Resident Level Year Level

Rotations*

Junior I General Surgery

Intermediate II

&

III

General Surgery, Out-patient Clinics, Emergency Room

Plastic & Reconstructive Surgery, Pediatric Surgery, Orthopedic Surgery, Urologic Surgery, Neurosurgery,

Thoracic and Cardiovascular Surgery

Senior IV & V

Surgery for Trauma, General Surgery (Critical Care & Nutrition, Minimal

Invasive Surgery, Surgical Oncology)

*Note: Please refer to Instructional Designs for each year level on pages 35-46

33

J. THE RESOURCES In order to attain the objectives of residency training, there are resources that should be provided. There must be a sufficient number of trainers, to oversee the implementation of the program, to participate in the teaching-learning activities, and to evaluate the residents in training. There must be adequate hospital facilities and clinical material to expose the residents to the common surgical problems, provide them hands-on experience in diagnosis and management, give them opportunity to develop, not only the knowledge and skills, but the proper values and attitudes in the practice of Surgery. A. THE HOSPITAL

1. Bed Capacity 2. Outpatient Facilities 3. Pathology Services 4. Radiology Services 5. Ultrasound 6. Blood bank or facilities for blood storage 7. Medical Library 8. Emergency Room 9. Operating Room 10. Recovery Room 11. Critical Care Facilities 12. Tumor Board and Hospital Tumor Registry 13. Major Clinical departments 14. Clinical material

B. The FACULTY

1. The Chairman 2. The Training Officer / Training Committee 3. The Consultant Staff - Minimum of 3 PSGS Fellows

C. The CASE MATERIAL volume of cases per program is at least 100 major

cases/5 residents/year with sufficient variety

34

K. EVALUATION

A. THE RESIDENTS PERFORMANCE

Evaluation Method Measurement Tool

1. Basic theoretical knowledge Written Exams

Oral Exams 2. Clinical Competence Direct Observation

Rating Scales Record Review 3. Technical Skills Direct Observation

Rating Scales Record Review 4. Attitudinal Competencies Direct Observation

Rating Scales Critical Incident Reports B. THE PROGRAM

Components

1. The structure Visit by the PSGS Committee 2. The activities on Accreditation 3. The resources Annual Report

35

PART II

INSTRUCTIONAL DESIGN

Junior Resident Level I (First Year) Rotation: General Surgery

INTENDED LEARNING

OUTCOMES

CONTENT

LEARNING ACTIVITIES

RESOURCES

EVALUATION

At the end of the FIRST year, the RESIDENT should be able to:

1. COGNITIVE 1.1. Discuss the principles of diagnosis and management of common general surgical disorders. 1.2. Discuss WHO Patient

1. Surgical Anatomy, Physiology, General Pathology

2. Ward Procedures 3. Wound Healing 4. Endocrine, Metabolic and

Immunologic Response to Injury.

5. Fluids and Electrolytes 6. Shock and Resuscitation 7. Bleeding and Blood

Transfusion 8. Principles of Surgical

Infections and antibiotics; Asepsis and Antisepsis

9. Surgical Complications 10. Trauma Epidemiology &

Prevention, Extrication& Trans- port, Triage, Patterns of Injury, Basic Life Support, Scoring System, Trauma Center

11. Minimally Invasive Surgery Advantages and Disadvantages of MIS Approach, Pathophysiology of Pneumoperitoneum, Pathophysiology of General Anesthesia, Operating room set-up, Equipment, Optical devices, Instrumentation for Access, Equipment for creating domain, Energy Sources, Ergonomics, Basic Skills

12. Surgical Oncology refer to Curriculum

13. Basic Surgical Nutrition Fluid & Nutrition Requirements Nutrition screening and Risk Assessment

14. Patient Safety Appropriate

Large Group Learning 1. Grand rounds 2. Pre and Postoperative Conferences 3. Mortality and Morbidity Conferences 4. Admitting rounds/ Endorsement 5. Lectures 6. Journal Club 7. Interdisciplinary Tumor Conference 8. Ward rounds 9. Workshops in Research Methodology & Critical Appraisal of Literature Small Group Learning 1. Group Discussion 2. Group Tutorial 3. Brainstorming

Independent Learning 1. Individual Study 2. Self-Instructional

Materials Lecturette Demonstration Role Playing Simulation

1. Textbooks

Principles of Surgery

Anatomy

Surgical Anatomy

Physiology

Pathology

Problem-oriented Surgical Diagnosis

Evidence Based Surgery 2. Access to all PCS/PSGS Evidence based guidelines 3. Textbooks and manuals of nutrition 4. Audio Video Equipment 5. Journals

PJSS

Foreign journals 6. Consultant Staff 7. Internet 8. CD on Minimal Access

Surgery 9. ICD 10 Manual 10.Committee on Research 11. The SAGES Manual:

Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy 2

nd Ed.,

Carol E.H. Scott Cooner (ed.)

Mastery of

Endoscopic and Laparoscopic Surgery, 3

rd Ed.,

Nathaniel J. Soper, Lee L. Swanstrom, W. Stephen Eubanks

Written Exams

Oral examinations

Direct Observation

Oral examination

36

Safety Framework based on the WHO Patient Safety Curriculum.

A. Discuss how to effectively communicate to patient

B. Discuss how to

prevent, identify and/or manage near miss injuries or adverse events.

C. Demonstrate how to work safely in the workplace

D. Applies evidence based practice and updated information technology

E. Discuss medication safety

F. Applies Infection Control principles.

1.3. Demonstrate knowledge of the principles of Research Methodology and Critical Appraisal of Literature.

Communicating Skills Communicating Risks Open Disclosures Obtaining Consents Delivering bad news Respect to cultural and religious diversity Recognizing reporting and managing near miss and adverse events Managing risks Understanding health care errors Managing complaints Showing leadership and being team player Understanding complex health organization Understanding human factors Providing continuity of care Managing fatigue and stress Employing available best evidence based practice Using information technology to enhance safety Preventing wrong patient, drug, dose, route ,timing in medication Rational antibioitic use 5 moments of handwashing Preventing surgical site infection 15. Basic surgical skills 16.Research Methods & Critical Appraisal of Literature

2. PSYCHOMOTOR

2.l. Evaluate surgical patients

a. Obtain an adequate history

b. Perform a thorough physical exam

c. Order pertinent laboratory and diagnostic exams

d. Formulate a logical diagnosis

e. Formulate treatment plan

f. Refer appropriately g. Provide continuing

Care

1. Signs and Symptoms of Diseases

2. Diagnostic Procedures 3. Principles of management of

patients with diseases of the: a. Alimentary tract b. Abdomen and its contents c. The breast d. The head and neck e. The vascular system f. The endocrine system, skin and soft tissues

Ward and OPD work 1. Ward / OPD patients 2. Radiology facilities 3. Central Laboratory 4. Consultant Staff

Observation using rating scale

2.2. Perform minor surgical procedures

A. Pre-operative care: Optimization

B. Pre-operative Skills 1. Biopsy

Incisional

Excision

FNAB

1. Performing minor surgical operations

1. Operating Room facilities 2. Outpatient facilities 3. Pathology 4. Atlas of Operative Technique 5. PCS Basic & Advanced

Direct Observation using rating scale

Record Review

Logbook or Records

37

2. Venous access 3. Intubation

Endotracheal

NGT

Foley catheter 4. Endoscopy

Proctosigmoidoscopy

Anoscopy

Laryngoscopy

Surgical Skills CD Manual

6. Surgical Skills Lab

(optional)

Operative Skills 1. I & D 2. Local anesthetic infiltration 3. Local excision of surface

lesions 4. Cricothyroidotomy 5. Tracheostomy 6. DPL 7. Aspiration of body cavities

Thoracentesis

Pericardiocentesis

Paracentesis 8. Assisting Operations 9. Circumcision 10. Electrocautery of warts 11. Simple appendectomy

1. Assisting in surgical procedures

2. Independent Learning

Individual Study

Self-Instructional Materials

1. Consultant staff 2. ER, RR, Critical care

facilities 3. Case material 4. Textbook on

Complications of Surgical Operations

5. Internet 6. Demonstration 7. Teaching aids, videos,

audio tapes

Direct Observation

Rating Scales

Incident Reports

Post-operative care 1. Wound care 2. Care of tubes, drains

catheters 3. Stoma care

Direct Observation

Rating Scales

Incident Reports

2.3.Assist in the performance of surgical procedures done by consultants and other residents

1. Indications and contraindications

2. Complications detection and management

3. Gowning and gloving; patient preparation

Direct Observation

Rating Scales

Incident Reports

2.4. Perform CPR 2.5. Perform Nutrition screening and assessment

2.6. Demonstrate basic principles Of Minimal Invasive Surgery

2.7. Discuss WHO Patient Safety Framework

A. Display effective communication to patient

Basic Life Support

Perform Subjective Global Assessment and Compute for Caloric & Fluid Requirements

1. Identification of MIS

instruments 2. Proper Care of MIS equipment and Instruments 3. Setting up the MIS equipment 4. Patient positioning and

securing 5. Energy sources and safety 6. Basic skills in a training box 7. Camera Navigation

1. Appropriate

Communicating Skills 2. Communicating Risks 3. Open Disclosures 4. Obtaining Consents 5. Delivering bad news

1. CPR training 2. Return

demonstration

1. Instructors 2. BLS Workshop 3. Training mannequins

4. The SAGES Manual:

Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy 2

nd Ed.,

Carol E.H. Scott Cooner (ed.)

5. Mastery of

Endoscopic and Laparoscopic Surgery, 3

rd Ed.,


6. Laparoscopic tower

and instruments 7. Pelvic Trainor 8. Skills Lab

Direct Observation

Rating Scales

Checklist

Same as above

Same as above

Patient Satisfaction

Survey

Critical

Incident Report

Peer Review

38

B. Demonstrate how to prevent, identify and/or manage near miss injuries or adverse events.

C. Demonstrate how to work safely in the workplace

D. Applies evidence based practice and updated information technology

E. Apply principles of medication safety

F. Applies Infection

Control principles.

6. Respect to cultural and

religious diversity

7. Recognizing , reporting and managing near miss and adverse events

8. Managing risks

9. Understanding health care

errors

10. Managing complaints

11. Showing leadership and being team player

12. Understanding complex

health organization

13. Understanding human factors

14. Providing continuity of care

15. Managing fatigue and

stress

16. Employing available best evidence based practice

17. Using information

technology to enhance safety

18. Preventing wrong patient,

drug, dose, route, timing in medication

19. Rational antibiotic use

20. 5 moments of hand

washing

21. Preventing surgical site infection

22. Rational Use of Antibiotics

3. AFFECTIVE

3.1. Demonstrate the proper attitudes and habits in the practice of surgery

3.2. Shows ethical practices in the workplace

Expresses commitment to life long learning.

1. Intellectual Integrity 2. Moral, Ethical value 3. Reliability / Responsibility 4. Appropriate Bedside

Decorum / Relationship w/patient

5. Study / Work habits 6. Relationship with co-health

workers & superiors 7. Emotional maturity reaction to

emergency or stress 8. Social Responsibility

1. Simulation 2. Role Modeling 3. Mentoring 4. Resident as

Teacher program

1. Written Hospital

Policies and Procedures

2. Hospital Manual on Resident decorum

3. Faculty Members as

Direct Observation

Rating Scales

Checklist

Incident Reports 1. OSCE 2. Faculty Mentorship

& Role Modeling with self reflection in professionalism

3. Chart Review

39

role model 4. Code of Ethics of the

Medical Profession 5. PMA code of Ethics 6. PCS code of Ethics

4. Chart Audit 5. Global Evaluation

Form

6. Patient Satisfaction Survey

7. Peer Review

40

Intermediate Level Resident Level II & III (Second & 3rdYear) Rotations: General Surgery, Plastic Surgery, Pediatric Surgery, Orthopedics, Neurosurgery, TCVS, and Urology

INTENDED LEARNING

OUTCOMES

CONTENT

LEARNING ACTIVITIES

RESOURCES

EVALUATION

At the end of the SECOND and THIRD year, the RESIDENT should be able to:

1. COGNITIVE 1.1. Provide initial care to patients

with acute abdomen , trauma & other life threatening surgical conditions

1.2. Provide comprehensive care to patients consulting for common surgical disorders in out patient setting.

1.3. Apply the principles of the following in the management of a surgical disease.

1.3.1. Surgical Pathology 1.3.2. Imaging modalities

(Radiology, CT-scan, MRI, ultrasound, mammography, nuclear scan )

1.3.3. Surgical Endoscopy 1.3.4. Surgical Oncology 1.3.5. Surgical Critical Care 1.3.6. Minimal Access

Surgery 1.3.7. Trauma

1.4. Demonstrate knowledge of the diagnosis and management of disorders in the other surgical specialties.

1.4.1. Pediatric Surgery 1.4.2. Plastic Surgery 1.4.3. Urology 1.4.4. Orthopedics 1.4.5. Neurosurgery 1.4.6. Thoracic &

Cardiovascular 1.5. Given a patient with complex

General Surgery or subspecialty problem, the resident should be able to formulate a comprehensive management plan

1. Surgical diseases requiring medium surgical operations.

2. ER & OPD procedures 3. Common medium complex procedures

4. Surgical Pathology 5. Surgical Imaging 6. Minimally Invasive

Surgery

Patient Selection

Preoperative work up and evaluation

Methods of Access &pneumoperitoneum Prevention of complications in Laparoscopy

Laparoscopic Endosuturing & Extracorporeal Tying

Diagnostic Laparoscopy

Indications for Laparoscopic Appendectomy and Cholecystectomy

7. Surgical Oncology

Diagnosis & staging

Multimodal approach

Pre operative Adjuvant Treatment

Surgical extirpation

Post operative Adjuvant Therapy

Palliative Care 8. Surgical Critical Care &

Nutrition

Care of the Critically-ill patient

Nutritional support in critical illness, surgery, trauma, sepsis

Nutritional assessment

Nutritional support (parenteral & enteral)

Structured Supervised Rotation ER, OPD, OR, Ward duties Large Group Learning 1. Grand rounds 2. Pre and 3. Postoperative

Conferences 4. Mortality and

Morbidity 5. Admitting rounds 6. Census 7. Lecturette 8. Journal Club 9. Interdisciplinary

Tumor Conference 10. Clinicopathological

correlation during surgical conferences 11. Correlative

Radiology Conferences Participation in Postgraduate Courses & Workshops Small Group Learning 1. Group Discussion 2. Group Tutorial 3. Brainstorming 4. Ward Rounds 5. ER Consultations

Independent Learning

Individual Study


1. Textbook of Surgery 2. Textbook of Trauma 3.Textbook of Pathology 4.Textbook of Radiology

& Imaging Modalities 5.Textbook in Surgical

Ultrasound 6. The SAGES

Manual: Fundamentals of Laparoscopy, Thoracoscopy and GI Endoscopy 2

nd

Ed., Carol E.H. Scott Cooner (ed.)

7. Mastery of Endoscopic and Laparoscopic Surgery, 3

rd Ed.,


8. PCS BEST Course 9. PCS Evidence-

based guidelines in common surgical diseases

10. PCS Cancer Facts & Figures

11. Atlas of Surgical Operations

12. Emergency Room 13. Pathology service 14. Radiology service 15. Blood Bank 16. PCS IONS Manual 17. Textbooks

Pediatric surgery

Plastic surgery

Urology

Orthopedics

Neurosurgery

TCVS

Written Exam

Direct Observation

Records Review

Incident Reports

41

9. Trauma Advanced trauma care 10. Common Surgical Conditions in:

A. Pediatric Surgery

Common pediatric surgical conditions

Vascular access

Inguinal hernia / hydrocoele

Imperforate anus, other causes of intestinal obstruction

Abdominal trauma

Appendicitis

Intussusception

Rectal polyps

Soft tissue tumors

B. Plastic

Burns

Basal cell

Carcinoma

Squamous cell carcinoma

Melanoma

Pressure sores / decubitus ulcers

A. Urology

Common urologic disorders

Hydrocoele

Benign Prostatic Hypertrophy

Testicular torsion

Urolithiases

Kidney & bladder trauma

D. Orthopedics

Fractures (closed / open, long bones, digits, etc.)

Joint and ligamentous injuries, (dislocations, internal knee derangements, sprains, etc)

Bone tumors: benign and malignant

Infections (osteomyelitis, diabetic foot, joint abscess, deep palmar abscess, felon, etc.)

Evaluate musculoskeletal pain (low back pains, cervical strain, etc)

Surgical Critical Care

Surgical nutrition

Surgical Oncology

Trauma

18. Journals 19. Outpatient facilities 20. Medical Library 21. ER, RR, Critical

Care facilities 22. PCS critical care &

nutrition basic & advanced workshops

23. Audiovisual facilities

24. Internet

42

1.6. Discuss clinical teaching and evaluation principles.

1.6.1. Formulate a simple

instructional design for a teaching learning activity.

1.6.2. Design a complete lecture plan

1.6.3. Discuss the different small group learning activities

1.6.4. Discuss the different clinical teaching method.

1.6.5. Discuss the different clinical evaluation method.

E. Neurosurgery

Principles of management of patients with diseases of the central, peripheral, and autonomic nervous systems including their supporting structures and vascular supply

Common neurosurgical conditions

Recognition and initial management of increased intracranial pressure such as in trauma, space occupying lesion.

Head and spine trauma

F. Thoracic and Cardiovascular Surgery Principles of management of patients with

Hydrothorax (includes hemothorax & pyothorax)

Pneumothorax

Blunt & penetrating thoracic injuries

Peripheral vascular injuries

A. Instructional design (ID)

Definition

Parts of ID

Preparation B. Lecture

Definition

Body

Styles

Making it effective C. Small Group Learning

Definition

Activities

Conduct D. Clinical Teaching

Principles

Activities

Conduct

Audit E. Clinical evaluation

Written exam

OSCE

43

Direct observation by checklist and rating scales

Critical incident report

2. PSYCHOMOTOR 2.1. Perform minor, medium and

major procedures. 2.2. Correlate pathologic

process with clinical course of the disease

2.3. Interpret and correlate imaging modality pictures with disease process.

2.4. Render emergency trauma care and resuscitation

2.5. Demonstrate preparation in endoscopy & minimal

access surgical procedures 2.6. Assist and perform open

and minimally invasive surgical specialty procedures

2.7. Assist co-workers during surgical procedures

2.8 Demonstrate principles of clinical teaching and evaluation in training junior residents, clinical interns and clerks.

In Addition to Junior Level Skills

1. Surgical Endoscopy

Laryngoscopy

Proctosigmoidoscopy

Exposure to flexible endoscopy

2. Minimally Invasive Surgery

Setting up of lap tower

Basic MIS Skills - Tissue Grasping - Blunt Dissection - Clipping - Looping - Ligation In-continuity - Scissors - Specimen Extraction - Suturing Techniques - Stapling Techniques - Extra Corporeal and Intra corporeal knots (Roeder, Meltzer)

Trouble shooting

Instruments reprocessing and maintenance

Video Editing

3. General surgical procedures such as:

Hernia repair

Thyroid & parathyroid surgery

Mastectomy

Open Cholecystectomy

with or without CBD exploration

Splenectomy

Skin and soft tissue: Wide Excision

GI anastomoses and ostomies

Repair of perforated bowel

Resection of Intestines and colon

Exploratory Laparotomy for ruptured appendicitis

Hemorrhoidectomy and Fistulectomy, Sphincterotomy

1. Perform medium operations

2. Assist major operations

3. Skills lab Animate and inanimate

4. Supervised exposure to endoscopy & laparoscopy

1.Operating Room 2.Emergency Room 3.Surgical Wards 4.Radiology Service Radiologic , Ultrasound & Imaging Modalities 5.Pathology service 6. Phil. Society of Ultrasound in Surgery lectures & handouts 7.Actual & Simulated Patients 8.Simulated laboratories / venues -Inanimate/animate specimens


Instruments & trocars

Scopes

Energy sources

Laparoscopy Machine

Accredited PSGS workshops

Teaching Audio and Video facilities

10. OPD clinic 11.Specialty Clinics 12.Teaching tapes, CDs 13. Atlas of Surgical

Operations 14.Simulated venues /

laboratory 15.PCS IONS Manual 16.PCS advanced

surgical skills CD manual

Direct observation

Reports

CERES

44

4. Trauma operative management of traumatic injuries; perform FAST, if available

5. Surgical Critical Care &

Nutrition

Compute for the caloric and protein requirements surgical or otherwise critically ill patients

CV access for hyperalimentation

6.Surgical Oncology

Recommended surgical procedures for specific tumor sites.

7. Urology

Hydrocoelectomy

Nephrectomy for trauma

Suprapubic cystostomy

Cystolithotomy

Orchidopexy/ orchiecomy for testicular torsion

8. Pediatric Surgery

Saphenous vein cutdown

Herniotomy/ Hydrocoelectomy

Colostomy

Explor lap for trauma, acute abdomen,

Obstruction, Intussusception, Appendectomy

9. Orthopedics

Open fractures: initial debridement and irrigation, immobilization

Closed reduction of: Common Closed Fractures: clavicular, Colles, tibial, phalangeal

Dislocation: shoulder, elbow, hip

Amputation and disarticulation for various indications

Soft tissue tumors FNAB, marginal excision of superficial tumors

Common orthopedic procedures prep and draping splinting, casting, traction, taping

After-care of common orthopedic problems

45

Spine immobilization

10. Plastic and Reconstructive Surgery

Making the proper incisions

Harvesting of skin grafts

Skin grafting

Cleft lip repair

Flaps

Burn care 11. Neurosurgery

Cranial decompression for trauma (burr- hole and drainage/craniotomy for epidural hematoma)

12. Thoracic and Cardiovascular

Surgery

Thoracostomy

Pleurodesis for malignant effusion

Percutaneous transthoracic needle biopsy

Thoracotomy for thoracic trauma:

Pericardiostomy/ pericardiotomy /pericardiocentesis

Vascular repair for trauma

Vascular access: subclavian vein catherization, A-V fistula

Vein stripping

13. Post-operative care

Wound care

Care of tubes, drains catheters

Stoma care

Care of complications

Nutrition support

3. AFFECTIVE 3.1. Demonstrate the proper

attitudes and habits in the practice of surgery

1. Intellectual Integrity 2. Moral, Ethical value 3. Reliability / Responsibility 4. Appropriate bedside

decorum / Relationship w/patient

5. Study / Work habits 6. Relationship with co-health

workers & superiors 7. Emotional maturity reaction

to emergency or stress 8. Social Responsibility

Direct

Observation

Rating Scales

Incident Reports

46

Senior Level Resident Level IV & V (Fourth and Fifth Year) Rotations: General Surgery, Trauma, Critical Care, Minimal Access Surgery, Surgical Oncology

INTENDED LEARNING

OUTCOMES

CONTENT

LEARNING ACTIVITIES

RESOURCES

EVALUATION

At the end of the FOURTH and FIFTH year, the RESIDENT should be able to:

1. COGNITIVE 1.1. Apply the principles of

diagnosis and management of all General Surgical disorders.

1.2. Apply the principles of

diagnosis and management of all surgical specialty disorders

1.3. Demonstrate knowledge in the

definitive and continuing management of the trauma patient.

1.4. Demonstrate knowledge in the

critical management of the multiply injured patient

1.5.1. Apply the principles of

minimally invasive surgery in basic & advanced surgical procedures.

1.5.2. Discuss the prevention and

management of complications in Minimally Invasive Surgery

1.6.Apply the principles of quality and ethical surgical practice 1.7.Discuss the professional behaviors

1. Basic Surgery 2. General & Cancer Surgery 3. Specialty Surgery

4. Trauma

Diagnostic modalities Trauma radiology, FAST,

DPL

Definitive Management of Trauma Injuries; Intensive care and rehabilitation; critical care

Polytrauma management

Mass casualty and disaster management

5. Minimally Invasive

Surgery in:

Cholecystectomy with IOC

Acute Abdomen

Colon and Rectum

Hernia (Inguinal & Ventral )

1. Altruism 2. Compassion 3. Humility 4. Appropriate Physical

and Social Demeanor 5. Good Leadership

Qualities

Responsible

Accountable

Competent

Effective communicator

Punctual

Constructive

Collaborative 6. Ethical 7. Commitment to

Excellence

Large Group Learning 1. Grand rounds 2. Pre and 3. Postoperative

Conferences 4. Mortality and Morbidity 5. Admitting rounds 6. Census 7. Lecturette 8. Journal Club 9. Interdisciplinary Tumor

Conference 10. Clinicopathological

correlation during surgical conferences

11. Correlative Radiology Conferences

12. Postgraduate Course 13. Trauma Audit Small Group Learning 1. Group Discussion 2. Group Tutorial 3. Brainstorming 4. Ward Rounds 5. ER Consultation

Independent Learning 1. Individual Study 2. Self-Instructional

Materials 1. Independent Learning

Lectures 2. Workshop & Symposia

in professionalism 3. Conferences

1. Textbook of Trauma

2. Audiovisual facilities

3. Postgraduate courses

4. PCS BEST Course 5. Textbook of Critical

Care 6. Manual in Nutrition 7. Training seminars 8. Medical Library 9. Internet 10. Textbooks on

Research Methodology & Designs

11. Workshops on Critical Appraisal of Literature

12. Journals 13. Outpatient facilities 14. Emergency Room 15. Medical Library 16. Radiology service 17. Laboratory service 18. RR, CCU 19. Audiovisual aids 20. Internet 21. ATLS Manuals 22. Postgraduate

courses 23. Consultant Staff

Written Exams

Oral Exams

Incident Reports

IONS Forms

Cognitive - Standardized

assessment tool

- Pre/post testing of knowledge

- Standardized evaluation after conference

- Chart records & portfolio

47

1.8 Apply principles of leadership and management

1)Discuss learners institutional organizational chart. 2) Discuss the organization s vision & mission 3) Establish simple strategic plan and financial management for the organization.

8. Types of Organization 9. Formulating Vision and

Mission / Core Values 10. Leadership Skills 11. Managerial Skills 12. Strategic Planning (SWOT technique)

1. Lecturette 2. Small Group Learning 3. Mentorship

1. Resource

Persons 2. John Maxwell

Leadership books

3. Books in Organization & Management

4. Trainor

Oral Examination

Practical Examination

- Vision Missio - Strategic

Management - Financial

Management

2. PSYCHOMOTOR

2.1. Perform (selected per category) major and complex general surgical procedures

2.2. Perform selected surgical specialty procedures

2.3. Assist consultants during

surgical procedures

2.4. Assist junior and intermediate residents during surgical procedures

2.5. Manage multiple organ

system traumatic injuries

2.6. Apply critical care principles in the continuing care of the trauma patient.

2.7. Demonstrate techniques in

the management of the multiply injured patient.

2.8. Participate in mass casualty

and disaster management drills

2.9. Demonstrate proper

techniques in the use of staplers in gastrointestinal operations.

2.10. Perform basic minimally

invasive surgery

In Addition to Junior & Intermediate Level skills: 1. More complex and radical

operations in general surgery and the surgical specialties such as:

Radical Mastectomy

Neck dissections and combined operations

Parotid and other salivary gland operations

Esophageal surgery

Gastric surgery with or without vagotomy

Radical Gastrectomy

Liver resections

Biliary-enteric bypass

Pancreatectomy

Colectomies, abdomino- perineal resection

Portosystemic procedures

Ileal conduit

Major amputations

Adrenalectomy 2. Trauma

Perform Focused Assessment with Sonography in Trauma (FAST)

Multiple casualty

Hospital/ER Triage

Multiple organ system injuries

Care of the Critically Injured patient


Diagnostic Laparoscopy

Laparoscopic Cholecystectomy

Lapararoscopic Appendectomy

1. Clinical exposure 2. Supervised operations

3. Independent Learning

Individual Study


1. Drills 2. Workshops 3. Disaster preparedness 4. Mass casualty

capability building

5. Wet Clinics

6. Dry firing

7. Animal models

8. Simulation exercises

1. CCU 2. Operating Room 3. Consultant Staff 1. Emergency Room 2. NDCC-PCS MOA 3. Internet 1. Teaching videos 2. Simulators

Logbook Entries

CERES

Incident Reports

Direct Observation

48

3. AFFECTIVE

1. Intellectual integrity 2. Moral, Ethical Value 3. Reliability/ Responsibility 4. Bedside decorum

relationship w/ patient 5. Study/ Work habits 6. Relationship with Co-

health workers 7. Emotional maturity

Reaction to emergency or stress

8. Social responsibility

49

PART III

EVALUATION SYSTEM FOR RESIDENTS IN GENERAL SURGERY

Background Information

This evaluation system is based upon the following:

1. The recommendations of a PCS workshop on Standardized Comprehensive Plan for Evaluation of Residents in Surgery held at Nikko Manila Garden on September 12, 1992. This was participated in by representatives from the Board of Regents, Committee on Residents & Scholars, Phil. Board of Surgery, Department Chairmen, Training Officers and Chief Residents of various selected institutions, with the technical assistance of Dr. Angeles T. Alora of NTTC-HP.

2. Careful, detailed research on principles of evaluation process and appropriate use of evaluation instruments for different competencies.

3. Expert technical assistance from the NTTC-HP. 4. Deliberations by the PCS Committee on Surgical Training. 5. Pilot testing of the rating scales from July 1, 1993 December 31, 1993 in the following

hospitals 1. Rizal Medical Center 2. FEU-NRMF Hospital 3. Chinese General Hospital

6. 1998 surveys on The Implementation of the Standardized Surgical Curriculum and The Utilization of the PCS Standardized Evaluation System.

7. Multi-disciplinary Workshop on The Improvement of the Surgical Curriculum and Standardized Evaluation System conducted October 30, 1999

The evaluation of the performance of residents in general surgery shall be based upon 4 major components, namely:

1. Basic theoretical knowledge 2. Clinical competence 3. Technical skills

4. Attitudinal competencies

1. Basic theoretical knowledge shall be evaluated by means of comprehensive, objective written examinations. At least one (ideally, two) written examination shall be given to all residents each year, aside from the PSGS required Residency In - Service Training Examination. The scope or content coverage of the written examination shall be based on the cognitive competencies per year level shown in Appendix I-A.

Since the cognitive competencies of a resident are expected to be cumulative as he progresses from junior year to intermediate to senior year level, it is recommended that the examination be designed in such a way that the resident is required to answer questions in a cumulative fashion also. Thus, the first portion of the test shall include items covered

50

under intermediate year cognitive competencies and shall be answered by intermediate and senior level residents only. The last portion of the test shall cover senior level cognitive competencies and will be answered by senior level residents only.

1.1. Oral Examinations - Integration and application of basic theoretical knowledge into

theoretical surgical decision-making or problem-solving shall be tested by means of oral examinations. These oral exams shall be based on simulated clinical problems appropriate for the year level of training and shall be given at least once a year to all senior level residents or every after specialty rotation for intermediate level residents. This comprises 40% of the grade for senior level residents.

A rating scale for evaluation during a simulated oral examination is shown in Appendix II-A and shall be used for evaluation of performance in the oral exam.

1.2. PSGS required Residency In Service Training Examination comprises 50%

of grade for Junior level residents and 30% of grade for Senior level residents.

1.3. Departmental Written Examinations comprises 50% of grade for Junior level residents and 30% of grade for Senior level residents.

The specific number of items to be given in the written and oral examinations per year level as well as the proportional weight to be given to these exams (as well as the PBS In-Service exam) in the computation of scores under Basic Theoretical knowledge shall be left to the discretion of the individual training program.

2. Overall clinical competence shall be evaluated by means of an observational rating scale (see Appendix II-B) based on a careful and close observation of the residents behavior and performance in actual clinical setting. Evaluation shall be done as frequently as possible (a minimum of quarterly or end of rotation evaluation is recommended). In addition, as many sources of evaluation (or raters) as possible should be obtained to improve reliability. These include: Mortality/Morbidity statistics, Clinical outcome reports, feedbacks from consultants, co-residents, peers and even self-evaluation. Only trainers who can answer 5 out of the 6 criteria may qualify as raters. The proportion of weights to be given to the different rotations and different raters in the computation of scores under clinical competence shall be left to the discretion of the training program.

3. Technical skills in the performance of surgical procedures and operations shall be

evaluated by means of supervised observation of the residents as they perform the procedure/operation. Technical mastery is obtained in stages: the trainee starts learning by assisting in operations, then a period wherein the trainee is closely supervised when doing a surgical procedure and finally when the trainee is allowed to independently perform a surgical procedure of varying complexities and problems.

The specific procedures/operations to be performed and evaluated per year level are listed in Appendix I-B. The rating scale for evaluating the technical skill as demonstrated by the resident as he performs each procedure/operation is shown in Appendix II-C. Ideally, the rating scale shall be accomplished by the rater who observed and supervised the procedure/operation immediately upon conclusion of the operation.

51

The resident shall be evaluated on as many procedures appropriate for his level of training as possible. Only trainers who have supervised or carefully observed the residents during the performance of the procedure or can answer 6 out of 8 criteria shall qualify as raters. The results of evaluation shall be collated and reported preferably on a quarterly or end of rotation basis. The Comprehensive External Residents Evaluation System (CERES) conducted by the chapter may be utilized as an additional evaluation tool.

The duration of operation refers to what is acceptable within the institution. The NNIS Operative Procedure Category T-duration listing (see Appendix III), may be used as a guide.

Since expertise and proficiency in the performance of technical procedures are obtained with progressive experience, it is suggested that greater weight be given to evaluations made towards the end of a rotation rather than at the beginning. The specific number of procedures and percent weights to be given to each procedure and type of rater (Consultant, senior resident and peer) shall be left to the discretion of the training program.

4. Attitudinal competencies shall be evaluated by means of an observational rating scale based on prolonged, periodic evaluation of a residents behavior demonstrated in actual work setting. The rating scale is shown in Appendix II-D. Only trainers who have had the opportunity to carefully observe the residents behavior over a prolonged period of time, or can answer a minimum of 6 out of 8 criteria in the rating scale, may qualify as raters. The observational rating scale shall be accomplished by as many raters as possible at least quarterly or at the end of each rotation.

Again, the percent weights to be given to different sets of evaluation in the computation of a residents attitudinal performance shall be left to the discretion of the training program

MINIMUM PASS LEVEL (MPL)

A minimum pass level (MPL) shall be set for each major component of the evaluation per year of training and shall be set at 50% for each component for all year levels. Evaluation Component First Year MPL to Senior Year

Basic Theoretical Knowledge 50% Clinical Competence 50% Technical Skills 50% Attitudinal Competencies 50%

52

It is suggested that any resident, whose performance at the end of the year falls below the minimum pass level set in any single evaluation component shall be subjected to appropriate remedial measures or not recommended for promotion to a higher level of training. It must be emphasized that all 4 major component competencies expected of a surgeon are equally and individually important. Thus, serious deficiencies (failure to achieve minimum requirements) in one aspect of the evaluation cannot and should not be overcome by adequate performance in another aspect. COMPUTATION OF TOTAL SCORES. Weights shall be given to each of the 4 major evaluation components per year level of training to arrive at a total score for each resident. Basic Theoretical Knowledge 20% Clinical Competence 40% Technical Skills 20% Attitudinal Competencies 20% 100% It is recommended that the total scores be utilized more for ranking residents per year level. This may be utilized to help reach decisions on merit awards, chief residency positions, provision of salaried positions, etc. and not to decide on whether a resident is performing satisfactorily or not. PROVISIONS FOR FEEDBACK The detailed record of each residents performance shall be regularly collated and updated by a Training Committee chaired by the training officer. In addition, they should regularly meet with the residents (preferably individually) in order to fully inform them of the status of their performance, point out areas of strengths and weaknesses and specify areas of improvement. Measures for remedial or rehabilitative work should also be instituted for residents who fail to meet minimum standards. Residents shall be made aware of the criteria and basis for their evaluation so that they may be fully conscious of the expectations with regard their performance.

53

APPENDIX I -A

EVALUATION OF COGNITIVE COMPETENCIES

The following cognitive competencies are to be evaluated at different year levels with the corresponding evaluation tools to be used.

JUNIOR YEAR

1. Basic knowledge of surgical anatomy, physiology, pathology, oncology, metabolism, wound

healing, shock and critical care, resuscitation, immunology and organ transplantation, fluids and electrolytes, nutrition, trauma, burns and surgical infection.

2. Principles of diagnosis of common surgical disorders

2.1. Special diagnostic procedures ultrasound, CT scan, plain x-rays, contrast studies, MRI, intra-op cholangiogram

2.2. Endoscopic procedures esophagoscopy, gastroscopy, laryngoscopy, bronchoscopy, proctosigmoidoscopy, colonoscopy, choledochoscopy.

3. Interpretation of basic diagnostic and laboratory examinations like CBC, urinalysis, blood chemistry, chest x-ray, plain abdominal x-ray, IVP, barium enema, upper GI series, Gram staining, culture and sensitivity.

4. Principles of operative surgery

4.1. Asepsis and antisepsis 4.2. Identification and function of instruments 4.3. Sutures and knots types, properties, indications for use

5. Sound understandi

Documents

Standardized Curriculum in General Surgery 2012