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General Surgery CurriculumFF5126

Module Head :Dr (Ms). Saladina Jaszle Binti JasminAssistant: Dr (Mr).Azlanuddin bin Azman

I.INTRODUCTIONDuring the 7 week posting, the students will initially be given a week of refresher course which will includeseminars andlectureson specific topics plus demonstrations on basic surgical procedures (Appendix 1). Following this, they will bedivided into 2 groups; each group will be required to spend a 3 week rotation each in UKMMC and TelukIntan Hospital (Appendix 2). The group at UKMMC will be further divided based on the 5 units in General surgery consisting of ;

1. Breast and Endocrine Surgery2. Colorectal Surgery3. Hepatobiliary Surgery4. Vascular Surgery5. Minimally Invasive Surgery

These subgroups will consist of 5-15 students who will be taught by 5-10 lecturers.Each lecturer is required to teach at least weekly for a minimum of an hour. However,the leaders of these subgroups are responsible to contact the lecturers themselves, early in the posting, to arrange for these teaching sessions which are usually conducted in the wards. Other additional teaching sessions usually take place in the operation theatres, clinics and endoscopy suites. Students are exposed to the concept of senior clerkship during their surgical attachment. The senior clerkship serves to prepare the students to become familiar and competent in handling common surgical cases and perform simple day-to-day procedures as surgical house officers.The current module will give more emphasis in basic surgical emergencies and procedures. Apart from these, the general surgical posting also impartsthe personal and professional development module in the training. In line with the senior clerkship concept, the students are required to go on-call and perform as “Junior House Officers”.

All tasks(performed/observed) by the students must be immediately documented in their respective log books(Appendix 3) for verification/grading purposes by the supervising doctors/staff. At the end of each 3 week posting, the students need to get their supervisors’ report. Each student should at the end of the surgical posting have a total of 2 supervisor’s report; one from Teluk Intan Hospital and one from UKMMC.

The Friday of the 5 th week of posting is the dateline to submit a case report to the office for stamping of date of reception; those submitted thereafter will be rejected & the student will be given a zero for his/her case write-up. The end of posting test will be held in the surgical wards in UKMMC on the last day.Having completed the surgical posting, the students are expected to have acquired the necessary surgical knowledge and skills to enable them to be proficient house officers.

Year5 UKMMC General Surgery 2012/13

TelukIntan Hospital

Teaching Faculty :-

1) Mr Lewellyn Rajakumar-General Surgeon2) Mr Mohan Gopalakrishnan – General Surgeon3) UKM Lecturer from the Surgical Department – One lecturer per week for 2 sessions (1-2hours/session)

Guidelines and Role of Resident Teaching Faculty:

1. Each doctor is required to spend a minimum of four hours of student teaching/supervision per week. 2. Students should be supervised in history taking, physical examination and management of patients. Procedures that are stated in the log book (Appendix 3) should be supervised/demonstrated to them.3. Student presentations in the clinics, ward rounds and bedside teaching sessions should be documented by the students in their respective log books.4. Besides presentations, students are required to record all tasks performed, assisted or observed immediately in the log book ; these will need endorsement/grading by the supervising doctor/staff.5. Doctors are required to complete the supervisor’s report (Appendix 4) and hand to

The office in UKMMC in a sealed envelope to be given to the student group leader on their last day in Teluk Intan.

He/she will need to return these to the Surgical Department in UKMMC on the same/next working day.6. Doctors here are most welcomed to provide feedback/contact theYear 5 Module head/Assistant on any relevant issues.

The student leader will need to liase with EncikMarzuki or PuanKhairunnisaat the Undergraduate Office at UKMMC, in regards to:

1. Thesupply of gloves, aprons, hats & masks 2. Transport between UKMMC &TelukIntan Hospital

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III. MODULE LEARNING OUTCOMESGeneral :

At the end of year V, the students should be able to:

1. Assistas a junior doctor in the surgical wards under direct supervision of a medical officer.

2. Apply basic surgical knowledge and skills effectively, to practice safely and competently.

3. Participate as a team member and assume leadership role in relevant situations.

4. Conduct basic surgical procedures in the wardunder direct supervision of a medical officer/ staff, as deemed appropriate.

5. Commit to lifelong learning.

Specific Learning Outcomes :

At the end of the 7-week attachment, the student should be able to:

1. Satisfactory obtain a surgical history and perform physical examination.2. Request basic and specific investigations to assist in diagnosis and management of common surgical problems.

3. Interpret relevant findings to reach a correct diagnosis. 4. Understand and discuss appropriate management of common surgical diseases.

5. Discuss the principles of surgical practice in the management of surgical patients.

6. Understand the ethical and medico-legal issues in the management of surgical patients.7. Perform simple ward procedures competently. (e.g: phlebotomy, bladdercatheterization, blood taking, setting up an intravenous drip)8. Assist in simple surgical procedures (e.g: insertion of chest tube, excision of

lumps, toilet and suturing)9.Participate in the collaborative management involving allied healthcare personnel (e.g: pharmacist, nutritionist, physiotherapist, rehabilitationist, and social services available) in the management of surgical patients.10.Understandskills in dealing with uncertainty, death and dying patients. 11.Demonstrate a sense of responsibility in interpersonal and professional conduct.

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IV. COURSE CONTENT

A. Clinical Topics

General Surgery( must know)

General Surgery( should know)

General Surgery( nice to know )

Trauma - ABC of trauma- primary survey- secondary survey- types of shock &management- types of trauma &principlemanagement- chest injury- head injury: types & management- genitourinary traumaEndocrine-benign thyroid diseases-thyroid malignancies-thyrotoxicosis-hypercalcaemia andhypocalcaemia

Endocrine-complications of thyroid surgery&management-primary and secondaryhyperparathyroidism-Cushing’s syndrome-Conn’s syndrome-phaechromocytoma

Endocrine-carcinoidtumour-insulinoma-adrenocortical carcinoma-anteriormediastinal mass-inflammatory thyroiddiseases

Breast- benign diseases- malignancies- nipple discharge

Breast-ductal carcinoma in situ-lobular carcinoma in situ-phyllodestumour-Paget’s disease-chronic granulomatousmastitis

Breast-reconstruction: types & indications-management of non palpablelesions

General- hernia :inguinal, ventral,femoral, incisional,paraumbilical&complications- lumpsand bumps;management- appendicitis

General- types and managementof enterocutaneousfistulaes

Upper GI-peptic ulcer disease-gastric carcinoma-oesophageal carcinoma-reflux

Upper GI-Barrett’s oesophagus-oesophageal corrosiveinjuries-gastric lymphoma

Upper GI-hiatus hernia

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-achalasia-haemorrhage& acutemanagement

-gastric outlet obstruction

Hepatobiliary- surgical jaundice- benign biliary duct disease- malignant biliary ductdisease- hepatictumours- pancreatitis- pancreatic carcinoma

Hepatobiliary-imaging modalities forinvestigation of diseases-chronic liver disease-portal hypertension

Hepatobilliary-hepaticencephalopathy-hepatolithiasis

Colorectal-haemorrhage&acutemanagement- acute intestinal obstruction- carcinoma- diverticular disease- haemorrhoids- fistulae in ano-ischiorectal abscess- principle of stomas

Colorectal-Famillialadenomatouspolyp-sigmoid volvulus-inflammatory boweldisease-tuberculosis-anal fissure-anal carcinoma

Colorectal-rectal prolapse-anal sphincter injury-chronic constipation-radiationproctitis-ischaemic colitis

Vascular-acute& chronic limbischaemia-varicose veins-chronic venous insufficiency-thrombosis-abdominal aortic aneurysm

Vascular- access and chemo-portmanagement-trauma- mycotic aneurysms

Vascular- vasculitides- upper limb ischaemia

Paediatric Surgery-bilious vomiting in neonates-acute abdomen in infants-surgical jaundice in infants-solid organ injury in children-inguino-scrotal swelling in children-intestinal obstruction

Paediatric Surgery-common abdominaltumours in children

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Urology-haematuria: causes &management-benign prostatic hyperplasia-genitourinary calculi-management of testicularpain

Urology-management of testicularswelling-Fournier’s Gangrene

Urology-prostate carcinoma

Plastic Surgery-benign and malignant skinlesions-benign and malignant oral lesions-burns& management

Plastic Surgery- parotidtumours

Neurosurgery- brain abscess

Neurosurgery-braintumours-spinal cord compression-hydrocephalus

B.Clinical procedures

To perform under supervision To observe

-venous blood taking-intravenous drip-insertion/removal of venofix-blood culture & sensitivity-insertion/removal of urinary catheter-insertion/removal of nasogastric tube-removal of sutures-wound dressing-digital per rectal examination-proctoscopy (+/- enema insertion)

-taking informed consent-arterial blood gas-fine needle aspiration cytology ( FNAC)-core-biopsy-insertion of Sengstaken- Blakemoore tube-suprapubic catherisation-insertion/removal of chest tube-insertion of central venous line-banding of haemorrhoids-incision and drainage-stoma care-endoscopy (OGDS/ERCP/colonoscopy/sigmoidoscopy)

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V. TEACHING-LEARNING METHODOLOGY

A. Workshop , Lectures &Seminars in the 1 st week 1)A workshop will include briefing and demonstrations on -basic clinical procedures -asepsis / sterility -handling of basic surgical instruments2)Seminar& Lectures on core surgical topics -will be facilitated by designated lecturers

B. Clinical Teaching RoundsStudents are expected to attend ward roundseveryday according to their respective teams. They are expected to perform as junior house officer and participate in the team’s patient care. They are expected to present the cases during the ward rounds.

C. WardworkStudents are expected to work together with the house officers and medical officers after the clinical teaching rounds. Apart from tagging in the wards, students are also expected to go to the outpatient clinics, operating theatres and endoscopy suites to clerk patients and to observe procedures.Whilst in the ward, the students are also expected to observethe work of the allied health providers and provide assistancein the day to day running of the ward (ie; Dietician, Pharmacist, Physiotherapist, etc.) in the co-management of surgical patients.

D. Bed side teachingThe students are expected to arrange the bed side teaching with their respective lecturers/doctors.During these teaching sessions, the students may discuss problem-based learning, patient management, case presentations or perform clinical examination under supervision.

E. On-callsStudents will be allocated on-call duty according to their respective teams, generally once alternate week. They are expected to tag along the Medical Officer On-call for that particular day as “junior House officer”. They are required to attend to patients at the Emergency Department, operating theatre, endoscopy suites and the wards. Students are expected to present the cases to the respective Medical officer/ Registrar / Lecturer.

On Call Duties:1.On-Call will be at UKMMC andTelukIntanHospital from 5pm to 12 midnight followed bya normal day the following day.2.On-Call duties must be emphasized parallel as the concept of junior clerkship. Patients must be seen first-hand together with the house-officer on call, clerked, taken blood investigations and managed accordingly until reviewed by the medical officer/ specialist.3. Blood investigations will be taken by the student under the supervision of the house officer/ medical officer.4. All surgical procedures that are required of the Year V students will be under the supervision of the medical officer/specialist. 7


5. If a particular student is unable to do the call, he or she has to find a replacement for that particular day. 6. At any day, these cases could be asked to be presented and discussed in the groupbedside teaching by the supervisor.

F. Operation TheatreStudents are encouraged to “Scrub up “ and assist as a second assistant in both the main and day care operation theatres.

G. Continuous Medical Education (CME) activitiesStudents will be introduced to the concept of lifelong learning and are expected to participate in the department’s regular CMEs ie; Journal Club Presentation, Recap (Revision of clinical case management and presentation), Radiological conferences, Histopathological conferences, Surgical updates, Surgical research presentations(Surgitract), and Mortality & Morbidity meetings.

H. Clinical Proficiency Test ,CPT At the end of each posting there will be a formal assessment by the lectures. Each student will be given 20 minutes to examine/discuss a patient. The student will be tested for another 10 minutes on an instrument and/or radiograph.

VI. ABSENCE FROM POSTING ACTIVITIES/SCHEDULE

The students are required to attend all academic and clinical activities pertaining to their course module. The attendance is 100%. If a student is unwell and is absent, a medical certificate (m.c.) of illnessmust be produced to the respective lecturer on his/her return.

If a student is unable to attend a session due to involvement in any official extra-curricular activities, an official letter stating his/her involvement must be produced to the respective lecturer on his/her return.

The m.c.or letter, whichever may be the case, then needs to be given to the surgical department office for recording/filing.

VII. ASSESSMENT

Areas of AssessmentPercentage

i. Clinical Proficiency test - 50%ii. Supervisor’s reports(2) - 20% iii. Log Book - 20%iv. Case report - 10%

Total 100%

A student will need to acquire a minimum50% ofthetotal marksto be considered to have passed the surgical posting/module. 8


VIII. REFERENCES

A. Textbooks:

1. Forrest, Carter, Macleod: Principles and Practice of surgery. Churchill Livingstone, Latest Edition (2005).

2. Cushieri, Hennessy,Greenhalgh, Rowley and Grace; Clinical surgery.Blackwell science, Latest Edition (2003).

3. Williamson; Scott: An Aid to clinical Surgery. Churchill Livingstone, Latest Edition (2005).

4. Norman L Browse; An introduction to the Symptoms and Signs of Surgical Diseases. Latest Edition (2005).

B. Reference books:

1. Cushieri, Giles, Moossa; Essential Surgical Practice, Latest Edition(1996).2. Bailey and Love’s Short Practice of Surgery, Latest Edition (2004).

C. Web:

1. Surgical tutor- surgical-tutor.org.uk2. International journal of surgery - http://www. theijs.com

UPDATED: March 2012- Dept. of Surgery Year 5 Curriculum Committee

a. Mr. Hairol Othmanb. Mr Azlanuddin b. Azmanc. Mr. Noor Izham Ismaild. Ms Marjmin bt. Osman

1st Revision on the Updated Year 5 Curriculum, March 2012 - Dr Saladina Jaszle @ 28th April 2014

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http://www/


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APPENDIX 2: WEEKLY TIME-TABLE/ DEPARTMENT ACTIVITYA. UKMMC

Monday Tuesday Wednesday Thursday Friday

7.30am-8am CWR

8am – 9am Surgitract Recap CPC Radiology conference

Census/ HPE conference/ Surgitract

9am – 10am CWR

10am – 1pm Wardwork/Clinic/OT/Endoscopy

2pm- 3pm CWR

3pm- 5pm Bedside teaching (based on respective lecturer)

5pm-12 midnight

On-Call; Once alternate week

B. TELUK INTAN HOSPITAL

Monday Tuesday Wednesday Thursday Friday

8am – 10am CWR

GWR9am-12am

10am – 1pm Wardwork/Clinic/OT/Endoscopy

2pm- 3pm Wardwork

3pm- 5pm Bedside teaching (based on respective doctor); 4 hrs/week/per doctor& 3hrs/week/UKMMC lecturer

5pm-12 midnight

On-Call; Once alternate week

Abbreviation & Venue:CWR Clinical Ward RoundsGWR Grand Ward RoundCPC Clinico-pathological conference ;AuditoriumHPE conference Histopathologicalexamination conference , last

Friday of the month ; Pathology seminar roomRecap Revision of clinical patient managementSurgitractSurgical research presentations Radiology conference Radiology seminar room

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WEEKLY TIME TABLE

Week 1:UKMMC

CME/CPC ( 1 hr)

Demonstration/LectureSeminar

Ward Work/Bedside teaching

On call

Mon Dept CME (1 hr) Briefing (1 hr)Surg L1 (2 hrs)

Demonstration (2 hrs)Rad L1 (1 hr)

Tues Recap (1 hr) Surg L2 (2 hrs)SurgL3(1 ½ hrs)SurgL4(1 ½ hrs)SurgL5(1 ½ hrs)

Wed CPC (1 hr) SurgL6(1 ½ hrs)Sem 1 (2 hrs)Rad L2 (1 hr)

Sem 2 (1 ½ hrs)Thurs Radiology conf (1 hr) Sem 3 (1 ½ hrs)

SurgL7(1 ½hrs)Sem 4 (2 hrs)Rad L3 (I hr)

Fri Census/HPE/Surgitract(1 hr)

Sem 5(1 ½hrs)Sem 6(1 ½hrs)

Total 6 hrs 6 + 6.5 + 6 + 6 + 3= 27.5 hrs

Week 2-4:UKMMC

CME Clinic/OT/Endoscopy Ward Work Bedside Teaching

On call

Mon Dept CME (1 hr)12 hrs/week

2 hrs 1.5 hr

3.5 hrs/week(Alternate

week on call X1 ie 7 hrs per

call)

Tues Recap (1 hr) 2 hrs 1.5 hrWed CPC (1 hr) 2 hrs 1.5 hrThurs Radiology conf (1 hr) 2 hrs 1.5hr

Fri Census/HPE/Surgitract(1 hr)

2 hrs 1.5 hr

Per Week 5 hrs 12 hrs 10 hrs 7.5 hrs 3.5 hrs

Week 5-7:TelukIntan Hospital

CME/Others Clinic/OT/Endoscopy Ward Work/ Bedside Teaching

On call

Mon12 hrs/week 15 hrs/week 4 hrs/doctor/

week3hrs/

lecturer/week

3.5 hrs/week(Alternate

week on call X1 ie 7 hrs per

call)

TuesWedThurs Last Thurs: Return

Trip (2-5pm)Fri GWR (3 hrs)

Last Fri: Exam in UKMMC

(9am-1pm)Per Week 3 hrs 12 hours 15hrs 15 hrs 3.5 hrs

L: Lecture Sem: Seminar Surg: Surgical Rad:Radiology

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CREDIT HOURS

PROGRAMME UKMMC TELUK INTAN HOSPITAL

GRAND TOTAL

CME 21 6 27.0

Lecture/seminar 27.5 0 27.5

Bedside Teaching 22.5 45 67.5

On call 21 21.0

Case report 1x 6 hrs 6 0 6.0

OT/Clinic/Endoscopy 36 33 69.0

Ward work 30 41 71.0

TOTAL 155hrs 125 hrs 280hrs

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APPENDIX 3

Year V Log Book (FF5126)

Department of Surgery

Name:

Matric No. :

Session:

Group :

Posting date Begin : End :

Supervisor(s) :

1. 2.

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Lecturer(s) in charge :

1. 2.

Clinician(s) in charge :

Registrar: 1. 2.

Medical Officer: 1. 2.

House Officer: 1. 2.

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Procedures performed

No. Type Date Diagnosis Supervisor’s Name

Signature

1 Insertion of a venofix

( 5 cases)

2 Removal of a venofix

( 5 cases)

3 Insertion of a nasogastric tube

( 3 cases)

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4 Removal of a nasogastric tube

( 3 cases)

5 Insertion of a urinary catheter (2 cases)

6 Removal of aurinary catheter (2 cases)

7 Wound dressing

(3 cases)

8 Removal of sutures/ R.O.S

(3 cases)

9 Venepuncture 17


( 5 cases)

10 Digital rectal examination

& proctoscopy

( 3 cases)

11 Setting up an intravenous drip

( 3 cases)

12 Blood culture & sensitivity (3 cases)

Procedures observed18


No. Type Date Diagnosis Supervisor’s name

Signature

1 Arterial blood gas /puncture

2 Insertion of a central venous line

3 Insertion of a chest tube

4 Removal of a chest tube

5 Insertion of an enema

6 Core biopsy

7 Fine needle aspiration cytology

8 Rubber banding of piles

9 Suprapubic catheterization

10 Stoma care

11 Taking an informed consent

12 Toilet & suturing

Endoscopic observations 19


No. Type Date Diagnosis Supervisors’s name

Signature

1 OGDS

2 Colonoscopy

3 ERCP

On call duty20


No. Type of Procedure

Date Diagnosis Supervisor’s Name

Signature

Case Presentation 21


a) ClinicNo. Patient’s name RN Date Diagnosis Supervisor’s

nameSignature Marks

Pass: 5-10

Fail: 0-4

1

2

3

4

5

b) Ward round 22


No. Patient’s name RN Date Diagnosis Supervisor’s name

Signature Marks Pass: 5-10Fail: 0-4

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

C) Bedside Teaching

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No. Patient’s name RN Date Diagnosis Supervisor’s name

Signature MarksPass: 5-10Fail: 0-4

1

2

3

4

5

6

7

8

9

10

Operation Theatre:

Students are encouraged to “Scrub up “ and assist as a second assistant.

a)Main / General 24


No. Patient’s Name

RN Date Diagnosis Type of Surgery Surgeon’s Name

Signature

1

2

3

4

5

b) Daycare

No. Patient’s Name

RN Date Diagnosis Type of Surgery

Surgeon’s Name

Signature

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1

2

3

4

5

LOG BOOK ASSESSMENT

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No. Type Poor<40%

Satisfactory40-75%

Excellent>75%

1 Procedures performed 0 1 2

2 Procedures observed 0 1 2

3 Endoscopics observed 0 1 2

4 On call0 1 2

5 Clinic presentations 0 1 2

6 Ward roundpresentations 0 1 3

7 Bedside teaching

presentations0 1 3

8 Main OT0 1 2

9 Day care OT0 1 2

TOTAL (20%)

Assessor’s Signature:

Name/Stamp:

Date:

APPENDIX 4: SUPERVISOR’S REPORT

Name : Matric No. :Year : Date of Posting:

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Clinical AssessmentComponent Excellent (5) Good ( 4) Fair (3) Borderline(2) Fail ( 1)

1 History2 Examination3 Diagnostic skill4 Investigation5 Management6 Clinical knowledge

Professional AssessmentComponent Excellent (5) Good ( 4) Fair (3) Borderline (2) Fail ( 1)

7 Appearance8 Bedside manners9 Attitude10 Attendance

TOTAL SCORE

Total final score ( Clinical + Professional Assessment score ) = /50

Comment : ______________________________________________________________________________

_______________________________________________________________________

-------------------------------------------Date: Supervisor’s Signature & Stamp

APPENDIX 5:CLINICAL PROFICIENCY TEST

Student Name: Matric No.:28


Examiner 1: Examiner 2:

CASE 1 (Modified Long / Short Case)

Diagnosis:

Component Assessed

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Marks: /10

Lecturer’s Comment:

__________________________________________________________________________________________________________________________________________________________________________

CASE 2 (Instrument / Radiograph)

Diagnosis:

Component Assessed

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Marks: /10

Lecturer’s Comment:

__________________________________________________________________________________________________________________________________________________________________________

__________________ ___________________

Signature & StampSignature & Stamp

Date:

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