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
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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
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MESSAGE PSGS President 2007
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 Society’s 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
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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”):
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
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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
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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
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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.
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TABLE OF CONTENTS Message of PSGS President 2006 1 Message of PSGS President 2007 2 Preface to the 1st Edition 3 Preface to the 2nd Edition 4 Preface to the 3rd Edition 5 Dedication and Acknowledgements 6
Part I
I. Introduction 8 II. The Mission and Vision of the PSGS 10 III. The Surgical Curriculum 11 IV. Goal of the Training Program 12 V. The General Objective of the Training Program 12 VI. The Competencies 12 VII. Levels of Training 13 VIII. Intended Learning Outcomes 13 IX. The Course Content 15 X. Teaching-Learning Activities 25 XI. Organization of Rotations 26 XII. The Resources 27 XIII. Evaluation 28
Part II
The Instructional Design for the Surgical Curriculum 29
Part III The Evaluation System for Residents 38 Appendices 42 Glossary 68
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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, Parañaque, 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 Parañaque, 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.
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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.
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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.”
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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
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ELEMENTS OF THE SURGICAL CURRICULUM
A. GOAL OF THE TRAINING PROGRAM
To train Residents in General Surgery to assume the following roles: 1. Primarily as CLINICIANS or MEDICAL PRACTITIONERS providing direct patient care
to individuals with surgical disorders in different settings such as the community, the hospital, schools and different institutions.
It may be desirable but not mandatory to prepare the Residents for the following roles:
2. As 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. 4. As ADMINISTRATORS involved in managing and organizing the activities of institutions,
organizations or departments of the hospital.
B. 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. C. The COMPETENCIES – these are the ABILITIES that Residents in all levels of training have to acquire and develop.
Level I Junior Year First Year Level II Intermediate Years: Second Year Third Year Level III Senior Years: Fourth Year Fifth Year E. INTENDED LEARNING OUTCOMES A. At the end of the JUNIOR YEAR, the RESIDENT should be able to:
1. COGNITIVE DOMAIN 1.1. Understand 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 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:
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1. COGNITIVE DOMAIN
1.1. Understand and 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. Understand and apply the principles of diagnosis and management of GS and surgical specialty disorders.
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
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F. 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. A. BASIC SURGERY
1. FLUIDS AND ELECTROLYTES a. Normal composition of body fluids b. Fluid and electrolyte imbalance
i. Volume deficit and excess ii. Concentration changes
c. Acid base imbalance i. Respiratory acidosis/alkalosis ii. Metabolic acidosis/alkalosis
d. Principles of fluid and electrolyte therapy i. Parenteral solutions ii. Preoperative fluid therapy iii. Intraoperative and Postoperative fluid therapy
2. SHOCK & RESUSCITATION a. Definition b. Pathophysiology c. Types of shock d. Treatment
3. SURGICAL NUTRITION
a. Nutrient stores and body composition b. Nutritional requirements
i. Energy – fat and carbohydrate ii. Protein
c. Malnutrition d. Evaluation of Nutritional Status e. Nutritional therapy
i. Oral feeding ii. Enteral feeding iii. Parenteral feeding
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4. ENDOCRINE AND METABOLIC RESPONSE TO INJURY
a. Central nervous system and endocrine changes b. Metabolic changes
i. Energy, CHO, fat and protein-metabolism ii. Starvation iii. Metabolic effects of injury iv. Blood coagulation
c Acid-base balance, water and electrolyte metabolism d. Oxygen transport f. Organ system changes
5. WOUND HEALING a. Physiology of wound healing
- phases of wound healing b. Factors affecting healing c. Wound care
6 BLEEDING AND BLOOD TRANSFUSION a. Biology of normal hemostasis b. Blood coagulation
i. Intrinsic pathway ii. Extrinsic pathway iii. Fibrinolytic system
c. Clinical tests for hemostasis d. Clinical defects in hemostasis -manifestations and treatment e. Blood transfusion
i. Replacement/Component therapy ii. Indications iii. Complications
7. BURNS
a. Classification according to extent & depth b. Systemic changes c. Therapy
i. Airway ii. Fluid resuscitation, Rule of Nines, Brooke’s and Parkland
formulae iii. Burn wound care, skin grafting iv. Complications
8. SURGICAL ONCOLOGY
a. Molecular Biology and Oncogenesis a. Pathology b. Clinical Manifestations of Cancer c. Diagnosis and Staging d. Multidisciplinary management options
i. Surgery
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ii. Radiotherapy iii. Chemotherapy iv. Immunotherapy v. 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
i. Primary Survey ii. Resuscitation iii. Secondary Survey iv. Definitive Management
d. Management of Specific Injuries i. Head ii. Neck iii. Chest iv. Abdomen v. Extremities vi. 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. SURGICAL BACTERIOLOGY a. Sepsis, Asepsis and Antisepsis b. General Principles of Diagnosis, Antibiotic and Surgical Therapy c. Antibiotics: Classification, Principles, Therapy d. Specific Infections
i. Streptococcal ii. Staphylococcal iii. Clostridial iv. Gram negative infections v. Anaerobic infection vi. Fungal infections
d Surgical Aspects of Treatment 11. PRINCIPLES OF IMMUNOLOGY AND TRANSPLANTATION
a. Immunosuppression b. Clinical Tissue and Organ Transplantation c. Organ Preservation
12. RECOGNITION OF SURGICAL COMPLICATIONS Local – diagnosis and management Systemic – diagnosis and management
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13. MINIMALLY INVASIVE SURGERY a. Operating room set-up, instrumentation & equipments b. Diagnostic laparoscopy c. Laparoscopic procedures 14. PERIOPERATIVE CARE a. Patient preparation b. Co-morbidities and risk assessment c. Pain control d. Care of the critically-ill patient
B. CLINICAL SURGERY-GENERAL SURGERY
1. HEAD AND NECK
a. Physical Examination b. Diagnostic Work-up c. Congenital Masses
i. Thyroglossal cysts ii. Teratomas iii. Branchial clefts iv. Vascular tumors v. Hygromas
d. Noncongenital lesions i. Papillomas ii. Polyps iii. Dermoid tumors iv. Rhabdomyomas and Neurofibromas v. Chemodectomas
e. Malignancy i.. General Principles epidemiology, risk factors, clinical work-up,
therapeutic considerations ii. Neck cancer
- triangles of the neck - staging – TNM - surgical treatment- radical neck dissection
iii. Nasal Cavity and Paranasal sinuses iv. Nasopharynx v. Oropharynx vi. Salivary Glands
2. THE THYROID AND PARATHYROID GLANDS
a. Anatomy and Physiology b. Surgical Diseases
i. Hyperthyroidism/hypothyroidism – medical and surgical therapy
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ii. Thyroid neoplasms - diagnostic workup of the thyroid nodule - medical and surgical treatment of papillary, follicular,
medullary, anaplastic cancers iii. Hyperparathyroidism / hypoparathyroidism
- diagnostic approach - medical and surgical therapy
3. THE BREAST AND SOFT TISSUE
a. Breast i. Anatomy ii. Physical examination iii. Diagnostic studies iv. Disease conditions
Benign cystic changes breast abscess
fibroadenoma ductal papilloma Malignant ductal carcinoma lobular carcinoma special types of carcinoma sarcoma
v. TNM staging for cancer vi. Surgical treatment options vii. Other treatment modalities
Radiation therapy Hormonal therapy Chemotherapy
b. Soft Tissue Tumors i. Natural History ii. WHO classification of sarcomas iii. Clinical manifestations iv. Diagnosis and staging v. Treatment
- radical surgery - radiotherapy - chemotherapy
4. ABDOMINAL WALL DEFECTS AND HERNIAS a. Anatomy
i. Inguinal region ii. Umbilical region iii. Other areas
b. Clinical Manifestations c. Types of hernias
i. Umbilical
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ii. Indirect inguinal iii. Direct inguinal iv. Femoral v. Sliding vi. Ventral vii. Others
d. Complications e. Operative repair
i. Anterior approach ii. Posterior approach iii. Tension-free herniorraphy (mesh herniorraphy) iv. Surgical treatment for umbilical hernia v. Surgical treatment for strangulated hernias vi. Laparoscopic options
5. THE ESOPHAGUS
a. Anatomy and Physiology b. Motility disturbances and their treatment c. Diverticulae d. Esophageal Strictures (Benign) e. Esophageal Perforation f. Esophageal varices g. Malignant Tumors
i. Classification ii. Work-up iii. Surgical Resection and Reconstruction, Palliative procedures iv. Other management options
6. THE STOMACH AND DUODENUM
a. Anatomy b. Physiology of gastric acid secretion c. Diseases
i. Peptic Ulcer diathesis - Medical therapy - Surgical treatment for complications of perforation, bleeding,
obstruction ii. Gastric varices iii. Gastric Ulcers
- Work-up and treatment for benign and malignant ulcers iv. Gastric Cancer
d. Surgical Management and Techniques - Types of vagotomy, gastrectomy and reconstructive
procedures
7. THE SMALL-INTESTINE, COLON, RECTUM AND ANUS
a. Anatomy and Physiology b. Clinical signs and symptoms c. Diagnostic studies for lower GI-tract disorders
i. Radiology ii. Endoscopy
d. Specific conditions and their treatment i. Polyps ii. Intestinal Tuberculosis iii. Amoebic Colitis iv. Typhoid Enteritis v. Diverticular Disease vi. Crohn’s disease & ulcerative colitis vii. Volvulus viii. Rectal Prolapse ix. Intussusception x. Malignant conditions of the small intestines xi. Surgical lesions of the appendix – appendicitis, etc. xii. Colonic malignancies xiii. Hemorrhoids, Abscesses and Fistula-in-ano xiv. Anal Carcinoma xv. Condyloma Acuminata xvi. Trauma xvii. Others
8. THE LIVER, GALLBLADDER AND BILIARY TREE
a. Anatomy and physiology of the liver and biliary tree b. Specific Studies
- Liver Function Tests - Diagnostic Imaging
c. Clinical Manifestations of Liver and Biliary Tract Diseases d. Specific Conditions
i. Liver abscesses ii. Liver Cysts iii. Benign hepatic tumors iv. Primary and metastatic cancer of the liver v. Portal Hypertension vi. Gallstones vii. Acute and chronic cholecystitis viii. Cholangitis ix. Cholangiocarcinomas x. Choledochal cysts
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xi. Trauma xii. Others
e. Surgical Therapy i. Drainage of liver abscesses ii. Hepatic Resections iii. Shunting Procedures, Esophageal Transection and
devascularization iv. Procedures for diseases of the gall bladder and biliary tract v. Biliary-enteric Bypass for bile duct obstructions
- cholecystectomy w/ CBD exploration
9. THE PANCREAS & SPLEEN
a. Anatomy and Physiology i. Pancreas ii. Spleen
b. Diagnostic Considerations c. Diseases
i. Pancreatitis ii. Cysts & Pseudocysts iii. Pancreatic tumors iv. Pancreatic trauma v. Rupture of the spleen
d. Surgical treatment
10. ACUTE SURGICAL ABDOMEN
a. Definition of acute surgical abdomen b. Clinical manifestations c. Conditions which may mimic or give rise to acute surgical abdomen d. Clinical signs and symptoms e. Approach to patients with suspected acute surgical abdomen f. 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
a. Technical considerations in skin grafts & flaps b. Management of maxillofacial trauma c. Congenital anomalies
- cleft lip and palate d. Cosmetic surgery – Principles
i. Scar revision ii. Rhinoplasty iii. Blepharoplasty iv. Mammoplasty
3. UROLOGY
a. Anatomy and Physiology of GUT b. Diagnosis c. Disease Conditions and Treatment
i. Urinary calculi ii. Tumors – Renal, Bladder, Prostatic, Testicular iii. Urologic Trauma iv. Other Urologic Emergencies
a. Anuria due to obstructive uropathy, bilateral, outlet obstruction including neurogenic bladder
b. Acute scrotum (testicular torsion)
4. ORTHOPEDICS
a. Orthopedic Trauma i. Fractures ii. Common long bone fractures iii. Hand injuries
b. Orthopedic infection – Septic arthritis, osteomyelitis, Pott’s 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
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5. THORACIC AND CARDIOVASCULAR SURGERY
a. Anatomy and Physiology of the Heart & Lungs b. Common Surgical Conditions
i. Trauma ii. Peripheral Vascular injury iii. Diaphragmatic injury
c. Neoplasms i. Lung – primary and metastatic ii. Metastatic iii. Mediastinal tumors d. Infections i. Empyema thoracis e. Common Vascular conditions i. Peripheral vascular occlusive disease ii. Varicose veins iii. Abdominal aortic aneurysm f. Common Cardiac Conditions i. Pericardial effusion
6. NEUROSURGERY a. Anatomy and Physiology of the CNS b. Common surgical conditions
i. Recognition and initial management of increased ICP- trauma, space-occupying lesions
ii. Trauma – low velocity gun shot wounds c. Indications for use and interpretation of diagnostic tests-
skull x-ray, CT, angiogram
D. PRINCIPLES OF: 1. Radiology 2. Ultrasonography 3. Endoscopy, laparoscopy 4. CT scan, MRI, PET scan 5. Radioactive isotopes
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G. 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 Operating Room Emergency Room Intensive Care Facilities Outpatient Clinics Wards
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H. 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
Surgery for Trauma, General Surgery (Critical Care & Nutrition, Minimal
Access Surgery, Surgical Oncology)
*Note: Please refer to Instructional Designs for each year level on pages 29-37
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I. 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
28
J. 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
29
PART II
INSTRUCTIONAL DESIGN
Junior Resident Level I (First Year) Rotation: General Surgery
INTENDED LEARNING
OUTCOMES
CONTENT
LEARNING ACTIVITIES
RESOURCES
EVALUATI
ON 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 Demonstrate knowledge of the principles of Research Methodology and Critical Appraisal of Literature
1. Surgical Anatomy, Physiology, General Pathology
2. Ward Procedures 3. Wound Healing 4. Endocrine, Metabolic and
Immunologic Response to Injury.
5. Fluids and Electrolytes, Adult 6. Shock and Resuscitation, Adult 7. Surgical Nutrition – refer to the
Prevention, Extrication& Trans- port, Triage, Patterns of Injury, Basic Life Support, Scoring System, Trauma Center
12. Minimally Invasive Surgery – Operating room set-up, Optical devices, Instrumentation for Access, Equipment for creating domain, Energy Sources,
13. Surgical Oncology – refer to Curriculum
14. Basic surgical skills 15. Research Methods & Critical
Appraisal of Literature
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
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. PCS IONS Manual 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. Monograms, hand-outs
and textbooks on research methods
Written Exams Oral examinations Direct Observation Oral examination
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
Signs and Symptoms of Diseases Diagnostic Procedures 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 and (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
• Pre-operative care: Optimization Nutrition risk assessment and implementation of IONS
• Pre-operative Skills
1. Performing minor surgical operations
1. Operating Room facilities
2. Outpatient facilities 3. Pathology 4. Atlas of Operative
- Direct Observation using rating scale Record Review
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 Checklist Incident Reports
31
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. Provide initial care to patients with acute abdomen , trauma & other life threatening surgical conditions 2. Provide comprehensive care to patients consulting for common surgical disorders in out patient setting. 3. Apply the principles of the following in the management of a surgical disease.
3.3 Surgical Endoscopy 3.4 Surgical Oncology 3.5 Surgical Critical Care 3.6 Minimal Access Surgery 3.7 Trauma
4. Demonstrate knowledge of the diagnosis and management of disorders in the other surgical specialties.
4.1 Pediatric Surgery 4.2 Plastic Surgery 4.3 Urology 4.4 Orthopedics 4.5 Neurosurgery 4.6 Thoracic & Cardiovascular
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. Surgical Endoscopy & Minimally Invasive Surgery-
Methods & Priniciples of Surgical Endoscopy Methods of Access & pneumoperitoneum Laparoscopic Instrumentation Prevention of complications in Laparoscopy
Diagnostic Laparoscopy in malignancy staging & trauma
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) 9. Trauma – Advanced trauma care 10. Common Surgical Conditions in:
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 12) Participation in Postgraduate Courses & Workshops Small Group Learning 1)Group Discussion 2)Group Tutorial 3)Brainstorming 4) Ward Rounds 5) ER Consultations Independent Learning 1) Individual Study 2)Self-Instructional
Materials
1. Textbook of Surgery 2. Textbook of Trauma 3.Textbook of Pathology 4.Textbook of Radiology
& Imaging Modalities 5.Textbook in Surgical
Ultrasound 6. Textbook & Atlas of
Minimal Invasive Surgery
7. PCS BEST Course 8.PCS Evidence-based guidelines in common surgical diseases 9. PCS Cancer Facts & figures 10..Atlas of Surgical Operations 11. Emergency Room 12. Pathology service 13.Radiology service 14.Blood Bank 15, PCS IONS Manual 16.Textbooks
a. Pediatric surgery b. Plastic surgery c. Urology d. Orthopedics e. Neurosurgery f. TCVS g. Surgical Critical Care
h. Surgical nutrition i. Surgical Oncology j. Trauma
17.Journals
- Written Exam - Direct Observation - Records Review - Incident Reports
- Evaluate musculoskeletal pain (low back pains, cervical strain, etc)
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
18.Outpatient facilities 19.Medical Library 20.ER, RR, Critical Care facilities 21.PCS critical care & nutrition basic & advanced workshops 22. Audiovisual facilities 23. Internet
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f. Thoracic and
Cardiovascular Surgery Principles of management of
patients with Hydrothorax (includes hemothorax & pyothorax)
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/craniectomy for epidural hematoma)
12. Thoracic and
Cardiovascular Surgery - Thoracentesis - Thoracostomy - Pleurodesis for malignant
effusion - Percutaneous transthoracic
needle biopsy - Thoracotomy for thoracic
trauma: - Pericardiostomy/
pericardiotomy /pericardiocentesis - Vascular repair for trauma - Vascular access:
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subclavian vein catherization, A-V fistula
- Vein stripping
13. Post-operative care a. Wound care b. Care of tubes, drains
catheters c. Stoma care d. Care of complications e. 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
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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. Demonstrate knowledge in
the indications& principles of minimal access surgery in basic & some advanced surgical cases.
1.6. Apply the principles of quality
and ethical surgical practice
Basic Surgery General & Cancer Surgery Specialty Surgery 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 Minimal Access Surgery in : Gallbladder Hernia (Inguinal &
Ventral ) Malignancy staging Abdominal Trauma
- 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
- Textbook of Trauma - Audiovisual facilities - Postgraduate courses - PCS BEST Course - Textbook of Critical
Care - Manual in Nutrition - Training seminars - Medical Library - Internet - Textbooks on
Research Methodology & Designs
- Workshops on Critical Appraisal of Literature
- Journals - Outpatient facilities - Emergency Room - Medical Library - Radiology service - Laboratory service - RR, CCU - Audiovisual aids - Internet - ATLS Manuals - Postgraduate courses - Consultant Staff
Written Exams Oral Exams Incident Reports IONS Forms
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
In Addition to Junior & Intermediate Level skills: 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
Logbook Entries CERES Incident Reports Direct Observation
37
2.4. Manage multiple organ
system traumatic injuries 2.5. Apply critical care principles
in the continuing care of the trauma patient.
2.6. Demonstrate techniques in
the management of the multiply injured patient.
2.7. Participate in mass casualty
and disaster management drills 2.8. Demonstrate proper
techniques in the use of staplers in gastrointestinal operations.
2.9. Perform or assist in basic
minimal access surgery
Portosystemic procedures Ileal conduit Major amputations Adrenalectomy Trauma - Multiple casualty Hospital/ER Triage - Multiple organ system injuries - Care of the Critically Injured patient Advanced Surgical Skills Minimally Invasive Surgery Diagnostic Laparoscopy Laparoscopic
relationship w/ patient 5. Study/ Work habits 6. Relationship with Co-
health workers 7. Emotional maturity
Reaction to emergency or stress
8. Social responsibility
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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 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 required PBS In-Service 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.
39
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 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. PBS In-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 resident’s 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.
40
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. 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 resident’s 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 resident’s 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
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 resident’s 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.
42
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
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 understanding of pre-operative, intra-operative and post-operative care of patients with common surgical problems. 5.1. Pre-operative care
a. Evaluation of operative risk b. Preparation of patients (e.g. bowel prep, prep of toxic goiter, etc.)
5.2. Intra-operative care 5.3. Post-operative care
a. Wound care-dressings, local wound care, management of wound infection b. Drains, tubes and catheters – types, care, indications for use, timing of removal c. Stomas – types , care, appliances, complication d. Management of ileus e. Recognition of complications
6. Knowledge of research methodology & critical appraisal of literature
43
INTERMEDIATE YEARS 1. All first year competencies 2. Working knowledge of critical care and trauma principles 3. Principles of diagnosis and management of common general surgical problems 4. Principles of diagnosis and management of common subspecialty surgical conditions 5. Basic knowledge of surgical pathology, radiology and other imaging modalities 6. Surgical decision-making 7. Designing research studies (optional)
SENIOR YEARS 1. All competencies of junior and intermediate years 2. Comprehensive knowledge of all surgical conditions within the scope of general surgery 3. Surgical decision-making 4. Management of the critically-ill patient 5. Conducting research studies (optional)
44
APPENDIX I – B EVALUATION OF PSYCHOMOTOR COMPETENCIES
1. I & D 2. Local anesthetic infiltration bleeding 3. Local excision of surface lesions mangled digits 4. Cricothyroidotomy / tracheostomy 5. Aspiration of body activities
Pericardiotomy / Pericardiocentesis - for thoracic trauma:
- Vascular: repair for trauma - Vascular access: subclavian vein, AV fistula, vein stripping
1.6. Plastic and Reconstructive Surgery - Skin grafting - Cleft lip repair - Flaps
2. General Surgical Procedures 2.1. Hernia repair 2.2. Thyroid & parathyroid surgery 2.3. Mastectomy 2.4. Open Cholecystectomy with or without CBD
exploration 2.5. Splenectomy 2.6. Skin and soft tissue: Wide Excision
2.7. GI anastomoses and ostomies 2.8. Repair of perforated bowel 2.9. Resection of Intestines and colon
2.10. Exploratory Laparotomy for ruptured appendicitis 2.11. Hemorrhoidectomy and Fistulectomy, Sphincterotomy
-
45
APPENDIX I-B
EVALUATION OF PSYCHOMOTOR COMPETENCIES
SENIOR RESIDENT LEVEL In Addition to Junior and Intermediate level 1. Selected specialty procedures such as: 1.1. Ileal conduit 1.2. Major amputations 1.3. Adrenalectomy (optional) 2. Radical and Complex General Surgical Operations such
as: 2.1. Radical Mastectomy 2.2. Neck dissections and combined operations of the Head and Neck 2.3. Parotid and other salivary gland operations 2.4. Esophageal surgery 2.5. Gastric surgery with or without vagotomy 2.6. Radical Gastrectomy 2.7. Liver resections 2.8. Biliary-enteric bypass 2.9. Pancreatectomy 2.10. Colonic resections 2.11. Abdomino- perineal resection 2.12. Portosystemic procedures
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Appendix II-A
RATING SCALE FOR ORAL EXAMINATIONS
1 – poor 2 – marginal 3 - satisfactory 4 – good 5 – very good 6 - excellent
1. KNOWLEDGE BASE [ ] Not Observed
1 [ ] Poor knowledge of basic science and clinical information expected for appropriate discussion of case.
2 [ ] Has difficulty recalling basic science & clinical information expected for appropriate discussion of case
3 [ ] Occasionally has difficulty recalling basic science and clinical information and has difficulty correlating available data to the clinical situation
4 [ ] Has good recall of basic science and clinical information is able to correlate available data to the clinical situation
5 [ ] Knowledge base in basic science and clinical information is broad and comprehensive but is not up to date with current literature
6 [ ] Knowledge base in basic science and clinical information is broad and comprehensive, is up to date even with current literature
2. APPROPRIATE DIFFERENTIAL DIAGNOSIS/PROBLEM LIST [ ] Not Observed
1 [ ] Does not know how to use data to obtain differential diagnosis or problem list.
2 [ ] Frequently has difficulty using data to obtain differential diagnosis or problem list
3 [ ] Occasionally has difficulty using available data to obtain differential diagnosis; identifies problem list
4 [ ] Evaluates available data to obtain adequate differential diagnosis; identifies problem list
5 [ ] Evaluates available data logically and systematically to obtain adequate differential diagnosis; identifies problem list
6 [ ] Efficiently analyzes available data; synthesizes information to arrive at a differential diagnosis; identifies problem list
3. USE AND INTERPRETATION OF DIAGNOSTIC TESTS [ ] Not observed
1 [ ]
Does not know what diagnostic tests to request. Does not know how to interpret simple basic laboratory tests
2 [ ] Requested diagnostic tests are grossly incomplete and irrelevant; Has difficulty interpreting simple, basic lab tests.
3 [ ] Some important diagnostic tests are overlooked; has occasional difficulty interpreting basic lab tests.
4 [ ]
Diagnostic tests requested are complete. Has occasional difficulty interpreting basic laboratory tests.
5 [ ] Diagnostic test requested are complete; important tests are included and interpreted correctly
6 [ ]
Diagnostic tests are exhaustive & maximizes information gained. Alternative tests are planned out. Tests are interpreted precisely including complicated & difficult test results.
47
4. TREATMENT PLANNING [ ]
Not Observed
1 [ ] Treatment plan is incomplete and inappropriate and does not know important procedures/ treatment modalities
2 [ ] Treatment plan is incomplete or inappropriate important procedures/treatment modalities are frequently overlooked
3 [ ]
Treatment plan is fairly complete and appropriate but important procedures treatments are over-looked occasionally.
4 [ ] Treatment plan is complete and appropriate important procedures/ treatments are included but with no alternative plan
5 [ ] Treatment plan is complete, thorough and precise with appropriate important procedures/ treatment included has some difficulty coming up with alternative plans
6 [ ] Treatment plan is comprehensive thorough and precise; suggests appropriate alternative plans.
5. COMMUNICATION SKILLS [ ]
Not observed
1 [ ] Very poor communication skills, can not explain his thoughts and perception in a clear and organized manner.
2 [ ] Lacks communication skills, has difficulty explaining his thoughts and perception in a clear and organized manner
3 [ ] Tries to communicate and explain his thoughts and perceptions; occasionally unclear or disorganized; may be verbose
4 [ ] Able to communicate and explain his thoughts and perceptions but is sometimes disorganized
5 [ ] Communicates effectively and clearly
6 [ ] Highly articulate; communicates effectively & clearly; chosen words are appropriate, well-organized and concise (direct to the point}
6. INTELLECTUAL INTEGRITY [ ]
Not Observed
1 [ ] Intellectually dishonest, consistently tries to extract self out of a situation, blames others for mistakes
2 [ ] Frequently tries to extract self out of situations, occasionally accept mistakes but refuses to accept limitations
3 [ ] Occasionally tries to extract self out of situations, accepts mistakes but refuses to accept limitations
4 [ ] Demonstrates intellectual honesty but sometimes refuses to accept limitations
5 [ ] Intellectually honest; humbly accepts and corrects personal mistakes or limitations without hesitation.
6 [ ] Intellectually honest, humbly accepts personal mistakes or limitations w/o hesitation. Tries to learn from it.
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Appendix II-B RATING SCALE FOR OVERALL CLINICAL COMPETENCE
1 – poor 2 – marginal 3 – satisfactory 4 – good 5 – very good 6 – excellent 1. DATA BASE (HISTORY & PE)
[ ] Not Observed
1 [ ] Grossly inaccurate History and/or PE
2 [ ] History and PE fairly complete but some important information and findings are missing making a diagnosis difficult
3 [ ] History and PE complete for a correct diagnosis but with some subtle information missing
4 [ ] History & PE are complete & accurate pertinent and important information are included
5 [ ] History & PE obtained is thorough and precise
6 [ ] History and PE are thorough and precise and able to obtain other important information and PE maneuvers even for rare cases
2. USE AND INTERPRETATION OF DIAGNOSTIC TESTS
[ ] Not Observed
1 [ ] Requested diagnostic tests are grossly incomplete or irrelevant; Has difficulty interpreting simple, basic lab tests.
2 [ ] Some important diagnostic tests are overlooked; has occasional difficulty interpreting basic lab tests.
3 [ ] Diagnostic test are complete; important tests are included and interpreted correctly but some unnecessary tests included rendering it not cost effective
4 [ ] Diagnostic test are complete; important tests are included and interpreted correctly
5 [ ] Diagnostic tests are exhaustive and cost effective, alternative tests are planned out as results are received. Tests are interpreted correctly
6 [ ] Diagnostic tests are exhaustive and cost effective, alternative tests are planned out as results are received. Tests are interpreted correctly. Understands the use and interpretation of special tests
3. DIAGNOSIS & JUDGMENT / DECISION MAKING
[ ] Not observed
1 [ ]
Has difficulty making correct diagnosis or decisions even in simple clinical situations. Decisions are irrational & haphazard
2 [ ] Has some difficulty making correct diagnosis or decisions in common clinical situations
3 [ ] Establishes correct diagnosis in common surgical problems most of the time but needs improvement in making judgment
4 [ ]
Establishes correct diagnosis or makes clear & rational decisions in common clinical situations
5 [ ] Establishes correct diagnosis both common and difficult cases but needs some guidance in judgment for the difficult cases
6 [ ]
Diagnosis & decisions are consistently correct, well-founded and comprehensive, even in difficult clinical situations
4. PATIENT TREATMENT & MANAGEMENT (PRE & POST-OP)
49
[ ] Not Observed
1 [ ] Management and treatment strategies are haphazard even in common surgical problems, bordering on negligence in the care of patients
2 [ ] Common problems are managed poorly and haphazardly; rarely contributes constructively to management of difficult problems
3 [ ]
Common problems are managed satisfactorily; but has difficulty in managing difficult problems in a rational and independent manner
4 [ ] Common problems are managed appropriately and show enthusiasm to learn and contribute in difficult cases
5 [ ] Common problems are managed appropriately and efficiently; contributes well to management of difficult problems
6 [ ] Consistently constructive and self-reliant in approach to management of simple and even most difficult problems
5. ORAL PRESENTATIONS/ REPORTS/ REFERRALS
[ ]
Not observed
1 [ ] Unable to prepare oral presentations on time. Referrals are disorganized and inaccurate
2 [ ] Reports are disorganized, poorly integrated and difficult to follow
3 [ ] Reports are fairly accurate and understandable; occasionally disorganized or misses some important details
4 [ ] Reports are communicated clearly and accurate
5 [ ] Is able to report precisely and comprehensively; Includes additional minor information that are crucial to patient management
6 [ ] Oral presentations include reports on current literature and is able to correlate and apply such knowledge in the actual clinical setting
6. RECORD-KEEPING ABILITY
[ ] Not Observed
1 [ ] Written records/ reports are incomplete, inaccurate, Disorganized, difficult to understand
2 [ ] Has to be constantly reminded to complete records/reports
3 [ ] Written records/reports are fairly complete with occasional inaccuracies; important items are sometimes omitted; does record keeping in his own initiative
4 [ ] Major items necessary are recorded completely, accurately and legibly on own initiative
5 [ ] Written records / reports are thorough, comprehensive and concise
6 [ ] Written records / reports are comprehensive and concise, problems are explained in detail and updated daily based on the changes in the patient’s condition
7. AFTER CARE
[ ] Not observed
1 [ ]
Grossly neglects the appropriate after care (e.g. tubes, drains, wounds)
2 [ ] Occasionally neglects appropriate after care or neglects some minor important parts of after care (e.g. tubes, drains, wounds)
3 [ ] Does after care on own initiative however, needs guidance in the proper management (e.g. tubes, drains and wounds)
4 [ ] Provides appropriate and acceptable after care (e.g. tubes, drains, wounds) has some difficulty caring for complicated situations
5 [ ] After care is comprehensively and meticulously provided; even in complicated or difficult situation
6 [ ] After care is comprehensive even in complicated cases, preventive measures for post-op complications are instituted and if present is recognized early and measures are done to manage the complications properly
50
Appendix II-C RATING SCALE FOR TECHNICAL SKILLS
1 – poor 2 – marginal 3 – satisfactory 4 – good 5 – very good 6 - excellent
1. PATIENT PREPARATION [ ]
Not observed
1 [ ] Patient grossly inadequately prepared.
2 [ ] Patient prepared but some important steps in patient preparation overlooked or omitted
3 [ ] Some minor steps in patient preparation for procedure are overlooked or omitted but of no consequence to the procedure
4 [ ] All Important, major steps in patient preparation are performed
5 [ ] Patient is prepared for the procedure. All important major steps and almost all minor steps in patient preparation are performed
6 [ ] Patient well-prepared for procedure and includes attention to minor details
2. PREPARATION OF EQUIPMENT [ ]
Not observed
1 [ ] Fails to organize needed equipment and instruments essential to the surgery. Cannot proceed with procedure
2 [ ] Fails to organize some important equipment, instruments & supplies but may still proceed with the surgery
3 [ ] Fails to prepare some minor equipment, instruments & supplies. Absence does not affect surgery.
4 [ ] Organizes and prepares all equipment, instruments & supplies essential to procedure as much as the hospital or patient can provide
5 [ ] Organizes and prepares all equipment, instruments, and supplies essential to the procedure
6 [ ] Equipment, supplies and instruments are prepared comprehensively; includes alternative equipment for unexpected findings
3. OBSERVANCE OF BASIC SURGICAL PRINCIPLES [ ]
Not observed
1 [ ] Failed to observe and carry out basic surgical principles throughout the procedure posing danger to the patient.
2 [ ] Has major lapses in observance of basic surgical principles in some part of the procedure and not immediately recognized. Has to be reminded.
3 [ ] Has major lapses but immediately rectifies the situation.
4 [ ] Has occasional lapses and is of no consequence to the procedure.
5 [ ] Observed basic surgical principles throughout the procedure
6 [ ] Paid strict and meticulous attention to basic surgical principles throughout the procedure
4. TECHNICAL DEXTERITY [ ]
Not observed
1 [ ] Movements are grossly imprecise, and poorly coordinated
2 [ ] Movements are frequently imprecise or not well coordinated
3 [ ] Movements occasionally imprecise or not well-coordinated
4 [ ] Movements are accurate and well-coordinated
5 [ ] Movements highly precise and coordinated but shows awkwardness in difficult phases of the procedure
6 [ ] Movements are highly precise & well-coordinated I even in difficult phases of procedure
51
5. GENERAL CONDUCT OF PROCEDURE
[ ]
Not observed
1 [ ] Frequently omits major steps in performing procedure; disorganized; sequence frequently incorrect. Hazardous to the patient.
2 [ ] Occasionally missed some major steps in procedure; somewhat disorganized; some minor inaccuracies in sequence but will not be hazardous to patient
3 [ ]
Occasionally missed some major steps but operation was done in the proper sequence. No consequence to the patient.
4 [ ]
Performed major steps of
procedure and in the proper sequence
5 [ ] All steps (major & minor of the procedure were performed precisely, thoroughly and in clockwork fashion
6 [ ] All steps were performed precisely, thoroughly, in sequence. Unexpected events handled correctly
6. INTRA-OPERATIVE JUDGMENT [ ]
Not observed
1 [ ] Cannot make a decision even in simple procedures and findings
2 [ ] Finds difficulty making appropriate judgments or decisions even in simple procedures and findings
3 [ ] Has occasional difficulty making appropriate judgments or decisions as procedure unfolds or progresses in simple procedures
4 [ ] Is able to make appropriate judgments or decisions based on operative findings in uncomplicated procedures; has some difficulty in complicated situations
5 [ ] Able to make precise judgment or decision on operative findings with minimal supervision even in difficult or complicated situations
6 [ ] Makes precise and proper decisions independently in all intra-op findings; anticipates complications
7. DURATION OF PROCEDURE [ ]
Not observed
1 [ ] Unable to complete the procedure alone
2 [ ] Completes procedure thrice the acceptable time frame
3 [ ] Completes the procedure twice the prescribed time.
4 [ ] Completes procedure just beyond the prescribed time
5 [ ] Completes procedure within allotted period of time
6 [ ] Completes procedure significantly shorter than allotted period of time
52
Appendix II-D RATING SCALE FOR ATTITUDINAL COMPETENCIES
1 – poor 2 - marginal 3 - satisfactory 4 – good 5 – very good 6 - excellent
1. INTELLECTUAL INTEGRITY [ ]
Not Observed
1 [ ]
Intellectually dishonest; provides misleading information meant to deceive and protect himself; does not accept his limitations
2 [ ] Shows inconsistency in intellectual honesty; has a tendency to be dishonest especially when under pressure
3 [ ] Intellectually honest in most situations, will not volunteer incriminating information on anyone unless asked
4 [ ] Demonstrates intellectual integrity and honesty; accepts limitations
5 [ ] Demonstrates intellectual honesty even in difficult situation; accepts limitations without hesitation and makes conscious effort to improve on them.
6 [ ] Intellectually honest with consistency, volunteers information without second thoughts even if self incriminating
2. MORAL / ETHICAL VALUES
[ ]
Not Observed
1 [ ] Known to engage frequently in un-ethical practices inconsistent with accepted norms & values
2 [ ] Has loose understanding/delineating between ethical and unethical medical values and practices
3 [ ] Can understand / delineate between ethical and unethical medical values and practices but sometimes has a tendency to do unethical practices
4 [ ] Demonstrates occasional lapses in maintaining ethical values and uprightness
5 [ ] Practices are ethically and morally consistent with accepted norms
6 [ ] Highly ethical and morally upright; provides an excellent example to peers and subordinates
3. RELIABILITY/RESPONSIBILITY
[ ]
Not Observed
1 [ ] Irresponsible, unreliable; needs repeated reminders of assignment; does less than prescribe work
2 [ ] Performs duties and responsibilities but has to be reminded. Work sometimes not finished on time
3 [ ] Performs duties and responsibilities that are assigned to him. Works enough just to get by. Complains when given extra work
4 [ ] Performs duties promptly and efficiently without being reminded, Willing to do additional work when asked
5 [ ] Performs duties promptly and efficiently without being reminded; is resourceful and innovative; takes initiative to spend additional time
6 [ ] When done with own duties has initiative to take on additional work. Motivates co-workers to perform well
53
4. BEDSIDE DECORUM/ RELATIONSHIP WITH PATIENTS
[ ]
Not Observed
1 [ ] Tactless and disrespectful of patients feelings and privacy; antagonizes and generates negative feelings from patients
2 [ ] Shows respect and sensitivity towards patients and relatives, however has difficulty controlling personal feelings to “difficult” patients
3 [ ] Shows respect and sensitivity towards patients and relatives’ feelings, tends to be superficial, relates well only to “interesting” patients
4 [ ] Respectful of patients & relatives, relates effectively and establishes good rapport with patients, has some problems handling “difficult” situations
5 [ ] Considerate and sensitive to patient & relative feelings, establishes rapport with all the types of handling patients
6 [ ] Compassionate and caring, commands respect and able to mediate in misunderstandings between patients/relatives and hospital workers
5. STUDY/WORK HABITS [ ]
Not Observed
1 [ ] Fails to demonstrate know-ledge of required reading or accomplishment of assigned work; fails to attend rounds and conferences
2 [ ] Shows inconsistency in demonstrating knowledge of required readings, occasionally fails to accomplish assigned work. Sometimes absent from rounds and conferences
3 [ ] Demonstrates adequate knowledge of required reading, needs to be reminded to accomplish assigned work, occasionally late for rounds and conferences
4 [ ] Demonstrates knowledge of required & supplemental readings; accomplishes assigned work efficiently and promptly; regularly attends rounds & conferences
5 [ ] Extensively knowledgeable of required and supplemental material takes initiative to learn more about patient’s condition, never absent from rounds & conferences
6 [ ] Volunteers self for additional research work and presentation in conferences, knows each individual patient’s condition and is ready for rounds ahead of everyone else
6. RELATIONSHIP WITH CO-HEALTH WORKERS AND SOCIETY
[ ]
Not Observed
1 [ ] Uncooperative, disrespectful or disobedient to superiors, actions often thoughtless and cause unnecessary stress to others in health team
2 [ ] Has a tendency to show arrogance especially towards his juniors, occasionally shows disrespect to superiors
3 [ ] Usually cooperative, generally does own work that neither helps nor hinders the work of others
4 [ ] Cooperative, respectful and works well with others
5 [ ] Highly motivated and professional, elicit cooperation from other team members, admired by co-workers
6 [ ] Earns respect from his co-workers whether his senior or junior and is able to lead by example, shows fairness in the treatment of his juniors
7. EMOTIONAL MATURITY/ REACTION TO EMERGENCY OR STRESS
[ ]
Not Observed
1 [ ] Breaks down into panic and hysterics during stressful situations causing confusion in the workplace
2 [ ] Emotionally unstable; reac-tion inappropriate to situation; cannot cope with stresses of even ordinary situations
3 [ ] Generally stable personality with occasional lapses of confidence in his ability to handle common situations
4 [ ] Emotionally stable but has difficulty coping with the stresses of extraordinary, complex or highly stressful situations
5 [ ] Stable and confident even in the most demanding or stressful situations
6 [ ] Emotionally stable and in times of stress and emergency is able to take over and place the situation under control.
54
8. ACCEPTS OWN LIMITATIONS [ ] Not Observed
1 [ ] Arrogant, fails to call for help jeopardizing welfare of patient; fails to recognize limitations
2 [ ] Delays too much before calling for help when the need arises sometimes putting the welfare of the patient into jeopardy
3 [ ] Occasionally calls for help when the need arises; sometimes takes welfare of patient into consideration.
4 [ ] Generally takes welfare of patients into consideration but with occasional hesitation to call for help when the need arises
5 [ ] Calls for help whenever the need arises and generally takes welfare of patients into consideration
6 [ ] Humble, prioritize patients welfare and always calls for help when the need arises, recognizes own limitations
55
Appendix III Duration of Surgery by NNIS Operative Procedure Category (American J Infection Control 1992: 20(5):271 – 274, PJSS Apr – Jun 1994: 49 (2):56)
T- cut point representing the 75th percentile for each operation
Procedure Category T duration (hours) Coronary artery bypass graft 5 Cardiac surgery 5 Other cardiovascular system 2 Thoracic surgery 3 Other respiratory system 1
Appendectomy 1 Bile duct, liver or pancreatic surgery 4 Cholecystectomy 2 Colon surgery 3 Gastric surgery 3 Small bowel surgery 3 Laparotomy 2 Other digestive system 3 Limb amputation 1 Spinal fusion 3 Open reduction of fracture 2 Joint prosthesis 3 Other musculoskeletal system 2 Cesarean section 1 Abdominal hysterectomy 2 Vaginal hysterectomy 2 Other obstetrical procedures 1 Nephrectomy 3 Prostatectomy 4 Other genitourinary system 4 Head and neck surgery 4 Other ear, nose, mouth, pharynx 3 Craniotomy 4 Ventricular shunt 2 Other nervous system 2 Herniorrhaphy 2 Mastectomy 2 Organ transplant 7 Skin graft 2 Splenectomy 2 Vascular surgery 3 Other endocrine system 2 Other eye 2 Other hemic and lymphatic systems 2 Other integumentary system 2
56
APPENDIX IV
SURGICAL RESIDENTS’ EVALUATION SHEET
Rotation:_______________________ Period Covered: _______________To________________ Evaluator:___________________________Position:__________________________________ Signature________________________ Instructions: Kindly indicate on the spaces provided for, your evaluation of each resident’s performance based on the different criteria. Ratings should be indicated as follows: NO - Not observed 1 - Poor 3 - Satisfactory 5 – very good 2 - Marginal 4 - Good 6 – excellent
For more detailed definition of each rating, please consult the attached sheet. Indicating “NO” on more than 2 items in each general criteria may invalidate your evaluation. RESIDENT
I. CLINICAL COMPETENCE
Resident 1
Resident 2
Resident 3
Resident 4
1. Data Base (History taking & PE) 2. Use and Interpretation of
Diagnostic Tests
3. Diagnosis 4. Patient Treatment and Management
5. Oral Presentations/Reports/Referrals
6. Record keeping ability 7. After care Total Score for Clinical Competence % Rating for Clinical Competence
4. Technical Dexterity 5. Organization and Sequence 6. Operative Judgment 7. Duration of procedure
Total Score for Technical Skills % Rating for Technical Skills (Total Score/Maximum Possible Score x 100)
58
APPENDIX V INSTRUCTIONAL DESIGNS FOR SURGICAL SPECIALTY ROTATI ONS
PLASTIC SURGERY
OBJECTIVE CONTENT LEARNING ACTIVITI ES RESOURCES EVALUATION
At the end of the rotation, the learner should be able to;
1. Cognitive
1.1 Demonstrate knowledge of the diagnosis and management of common surgical skin disorders & malignancies.
1.2 Given a patient with plastic subspecialty problem, the resident should be able to formulate a comprehensive management plan.
1. Common Surgical Skin disorders a. Bburns b. Basal cell Carcinoma c. Squamous cell ca d. Melanoma e. Pressure sores/ Decubitus ulcers
I. Large Group Learning
1) Grand rounds 2) Pre and 3)Postoperative Conferences 4) Mortality and Morbidity 5) Admitting rounds 6) Census 7) Lecturette 8) Inter disciplinary Tumor Conference
II. Small Group Learning
1) Group Discussion 2) Group Tutorial 3) Brain Storming
III. Independent Learning
1) Individual Study 2) Self Instructional Materials
1. Operating room facilities / in patient facilities
2. Outpatient facilities
3. Pathology
4.Textbooks - Plastic surgery - Anatomy - Clinical Pathology
Written exam
Given a patient, the learner should be able to:
2. Psychomotor
2.1 Resuscitate and manage burn patients 2.3 Apply the appropriate incisions & margins of Incisions 2.4 Demonstrate when and how to use skin grafts and flaps.
1) Making the proper Incision
2) Harvesting of skin Grafts
3) Skin grafting
4) Cleft lip repair
5) Flaps
6) Burn care.
I. Large Group Learning
1) Pre and Postoperative Conferences 2) Lecturette
II. Small Group Learning 1) Group Discussion 2) Group Tutorial
III. Independent Learning 1) Individual Study 2) Self Instructional Materials
Activities in plastic surgical subspecialty (requiring each residents to perform or assist in adequate number of patients)
1. Operating room facilities / in patient Facilities
2. Outpatient facilities
3. Pathology
4.Textbooks - Surgery - Plastic
5. Surgery Consultant Staff
6. Plastic surgery instruments a. sutures b. dermatome or humbly knife
Direct observation 1)Rating scales 2) Checklists 3.)Incident reports
3. Affective - Demonstrating professional behavior in conducting evaluation of patient
Humility to recognize & accepts own strengths & limitations and knows when to ask helps to a plastic surgeon.
4) Emotional maturity – stable even in most stressful situation
5) Empathy stress 6) Social responsibility
I. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation II. Individualized Learning 1) Independent study of supplemental materials
1) Personal experiences of mentors & experts The Healing Cut
2) Bioethics books
3) Simulated & actual patients
4) Role modeling of Mentors
5) Clinical Practice Guidelines for plastic surgery
Direct observation with attitude scale Patient Evaluation Anecdotal records Incident reports
59
PEDIATRIC SURGERY
Objective
Content Teaching- Learning
Activities
Resources
Evaluation Given a patient, the learner should be able to : 1. Cognitive
1.1 Demonstrate knowledge of the diagnosis and management of common pediatric surgical conditions
1.2 Apply the principles of perioperative care a) Fluid & electrolytes b) Nutrition c) Antibiotic Utilization
Given a patient with pediatric subspecialty problem, the resident should be able to formulate a comprehensive management plan.
1) Grand rounds 2) Pre and 3) Postoperative Conferences 4) Mortality and Morbidity 5) Admitting rounds 6) Census 7) Lecturette 8) Inter disciplinary Tumor Conference
II. Small Group Learning
1) Group Discussion 2) Group Tutorial 3) Brain Storming
III. Independent Learning 1) Individual Study 2) Self Instructional Materials
Textbooks
Journals
Operating room / Outpatient facilities
Pathology services
Radiology services & ultrasound
Medical library
ER, RR, Critical care facilities
Pediatric Surgery Experts
CD of Pediatric surgery cases
Written exam Oral Examination
2. Psychomotor Assist or perform common pediatric surgical procedures
1) Vascular Access 2) Herniotomy/ Hydrocoelectomy 3) Thoracostomy 4) Explore lap for trauma acute abdomen, obstruction, appendectomy, intussusception, polypectomy
I. Large Group Learning
1) Lecturette 2) Film Showing - Demonstration
II. Small Group Learning
1) Small Group Discussion 2) Small Group Tutorial 3) Simulation 4) Assisting or performing actual pediatric surgery operations
Activities in pediatric surgical subspecialty (requiring each residents to perform or assist in adequate number of patients)
1. Operating room facilities / in patient facilities 2. Outpatient facilities 3. Pathology 4. Radiological facilities 5. Consultant staff 6. ER, RR, Critical care 7. Case material 8. Record review
Log book OR record
Pediatric Surgery Atlas
Direct observation Record review Logbooks OR record
3. Affective
3.1 Demonstrate the proper attitudes and habits in the practice of pediatric surgery 3.2 Humility to accept own limitations & knows when to refer to pediatric specialist
1. Intellectual integrity 2. Moral, Ethical Value 3. Reliability / Responsibility 4. Bedside decorum/ relationship with patient 5. Study/Work habits 6. Relationship with Co-health workers 7. Emotional maturity Reaction to emergency or stress 8. Social responsibility
I. Small Group Learning
1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation
II. Individualized Learning
- Independent study of supplemental materials
1. Ward rounds 2. Ward work 3. ER consultation 4. OPD consultation 5. Operating room
Direct observation Rating scale Incident reports
60
ORTHOPEDICS Objectives Content Learning
Activities Resources Evaluation
Given an orthopedic patient , the learner should able to:
1. Cognitive
1.1 Demonstrate knowledge of the diagnosis and management of common orthopedic disorders
1.2 Demonstrate the principles of immobilization
1.3 Apply principles of radiographic diagnostic procedures
– plain x-ray, CT, MRI
1.4 Demonstrate use of common orthopedic instruments/appliances
1.5 Given a patient with orthopedic subspecialty problem, the resident should be able to formulate a comprehensive management plan.
1. Fractures (closed / open, long bones, digits, etc.)
5. Evaluate musculoskeletal pain (low back pains, cervical strain, etc)
I. Large Group Learning 1) Lecturette 2) Weekly Census Conference 3) Trauma Census 4) Mortality & Morbidity Conference 5) Film Showing 6) Multi -disciplinary Conference 7) Monthly audit of in and out patient orthopedic patients
II. Small Group Learning 1) Small Group Discussion 2) Ward Rounds 3) Preceptorship 4) ER Conference
III. Independent Learning - Individual Study Period
Journals
Operating room / Outpatient facilities
Pathology services
Radiology services – CT Scan, MRI
Medical library
ER, RR, Critical care facilities
Orthopedic surgeons
CD of orthopedic surgical operations cases
Orthopedic Atlas
Written Exam
Given an actual patient, the learner should be able to :
2. Psychomotor Skills: – To perform or assist in common orthopedic procedures in emergency and elective settings
1. Fractures – closed reduction of common fractures (Colle’s, clavicle, phalangeal, etc.) and immobilization - open Fx – initial debridement, Irrigation and immobilization 2. Joint dislocations – reduction of shoulder, elbow, hip and phalangeal dislocation Do diagnostic maneuvers for internal knee derangements and other joints 3. Do disarticulation & amputations for various Indications 4. Soft tissue tumors – FNAB,
marginal excision of superficial tumors
5 Common orthopedic procedures prep and draping splinting, casting, traction, taping 7. After-care of common orthopedic problems 8. Spine immobilization
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration
II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation 4) Assisting in actual orthopedic operations
Activities in orthopedic subspecialty (requiring each residents to perform or assist in adequate number of patients
1. Operating room facilities/ in patient facilities
2. Outpatient facilities
3. Pathology
4. Radiological facilities
5. Consultant staff
6. ER, RR, Critical care
7. Case material
8. Record review Log book OR record
9. Orthopedic Atlas
Direct observation
1) Rating scale
2) Checklist
3. Affective 3.1 Demonstrate proper attitude and interest in learning orthopedic procedures that can be useful in general surgery practice
3.2 Humility to accept own limitations & knows when to refer to orthopedic specialists
4) Emotional maturity – stable even in most stressful situation
5) Empathy stress 6).Social responsibility
I. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation
II. Individualized Learning - Independent study of supplemental materials
1) Personal experiences of mentors & experts The Healing Cut
2) Bioethics books
Simulated & actual patients
Role modeling of Mentors
Clinical Practice Guidelines for orthopedic conditions
Direct observation 1)Rating scale 2)Checklist Incident Reports
61
NEUROSURGERY
OBJECTIVE CONTENT LEARNING ACTIVITIES RESOURCES EVA LUATION Given a patient , the learner should be able to:
1. Cognitive 1.1 Apply knowledge of
anatomy & physiology of the central & peripheral nervous system
1.2 Apply the principles of prevention, diagnosis, evaluation and recognition of common neurosurgical disorder.
2. Demonstrate knowledge of the diagnosis and management of common neurosurgical disorders
3.Determine indications for use and interpretation of common diagnostic test – skull x-ray, CT, MRI, Angiogram laboratories
4. Formulate a logical diagnosis, treatment plan & continuing care of common neurosurgical conditions
5. Given a patient with neurosurgical subspecialty problem, the resident should be able to formulate a comprehensive management plan.
1.1 Central nervous system, peripheral nervous system and autonomic nervous systems including their supporting structures and vascular supply
1.2 Common neurosurgical conditions
1.3 Recognition and initial management of increased intracranial pressure – such as in trauma, space occupying lesion. 1.4 Trauma – low velocity gun shot wound
I. Large Group Learning
1) Grand rounds 2) Pre and 3) Postoperative Conferences 4) Mortality and Morbidity 5) Admitting rounds 6) Census 7) Lecturette 8) Inter disciplinary Tumor Conference
II. Small Group Learning 1) Group Discussion 2) Group Tutorial 3) Brain Storming
III. Independent Learning 1) Individual Study 2) Self Instructional Materials
Textbooks
Journals
Operating room / Outpatient facilities
Pathology services
Radiology services – CT Scan, MRI
Medical library
ER, RR, Critical care facilities
Neurosurgical Experts
CD of Neurosurgical cases
Neurosurgical Atlas
Written Oral exam
2. Psychomotor Given an actual patient, the learner should be able to :
2.1 Perform the following:
Primary Survey Resuscitation Secondary Survey Initial and / or Definitive Management
2.2 Provide Early Proper Medications
2.3 Perform or assist neuro -surgical procedures
Cranial decompression for trauma (burr- hole and drainage/craniectomy for epidural hematoma
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration
II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation 4) Assisting in actual neurosurgical operations
Activities in neurosurgical subspecialty (requiring each residents to perform or assist in a number of patients)
1. Operating room facilities / in patient facilities 2. Outpatient facilities 3. Pathology 4. Radiological facilities 5. Consultant staff 6. ER, RR, Critical care 7. Case material 8. Record review Log book OR record
Neurosurgical Atlas
Direct observation Rating scale
Checklist
3. Affective –
3.1Demonstrates the proper attitudes and habits in the practice of neurosurgery 3.2 Humility to recognize & accepts own strengths & limitations and knows when to ask helps to a neurosurgeon specialist.
1) Intellectual Integrity - practices intellectual honesty 2) Appropriate Bedside Decorum 3) Team work – cooperate with other team members 4) Emotional maturity – stable even in most stressful situation 5) Empathy stress 6) Social responsibility
I. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation II. Individualized Learning - Independent study of supplemental materials
1) Personal experiences of mentors & experts The Healing Cut 2) Bioethics books
3) Simulated & actual patients 4) Role modeling of Mentors 5) Clinical Practice Guidelines for neurosurgical conditions
Direct observation
Rating scale Checklist Incident Reports
62
THORACIC & CARDIOVASCULAR SURGERY
OBJECTIVE CONTENT
TEACHING-LEARNING ACTIVITIES
RESOURCES
EVALUATION
1. Cognitive 1.1 Demonstrate knowledge of the diagnosis and management of common thoracic & cardiovascular disorders 1.2 Given a patient with thoracic & cardiovascular subspecialty problem, the resident should be able to formulate a comprehensive management plan.
Large Group Learning 1) Grand rounds 2) Pre and Postoperative Conferences 3) Mortality and Morbidity 4) Admitting rounds 5) Census 6) Lecturette 7) Inter disciplinary Tumor Conference Small Group Learning 1)Group Discussion 2)Group Tutorial 3)Brain Storming Independent Learning 1) Individual Study 2) Self Instructional Materials
1. Textbooks 2. Journal 3. Outpatient facilities 4. Pathology services 5. Radiology services 6. Medical library 7. ER, RR, OR, Critical Care Facilities 8. Consultant staff
Written exam Oral Exam Review of patient outcome (charts, logbooks)
2. Psychomotor Perform or assist thoracic and cardiovascular procedures
- Thoracentesis - thoracostomy - Pleurodesis for malignant effusion - percutaneous transthoracic needle biopsy - thoracotomy, pericardiostomy/ pericardiotomy/ pericardiocentesis for thoracic trauma: - vascular repair for trauma - vascular access: subclavian vein catherization, AV fistula - vein stripping
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation 4) Assisting in actual neurosurgical operations Activities in thoracic & cardiovascular specialty Perform previously listed procedures & assist in different thoracic and Cardiovascular procedures
1. Operating Room Facilities
- in patient - out patient
2. Outpatient facilities 3. Pathology 4. Radiological facilities 5. Consultant Staff 6. ER, RR, Critical Care 7. Case Material
Direct observation 1) Checklist 2. Rating scale Record review Logbooks OR Records
3. Affective 3.1 Demonstrate the proper attitiudes and habits in the practice of thoracic & cardiovascular 3.2 Humility to accept own limitations & knows when to refer to TCVS specialist
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
I. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation
II. Individualized Learning 1) Independent study of supplemental materials
1) Personal experiences of mentors & experts The Healing Cut 2) Bioethics books Simulated & actual patients Role modeling of Mentors Clinical Practice Guidelines for TCVS conditions
Direct observation 1.Rating scale 2. Checklist Incident reports
63
UROLOGY
OBJECTIVES CONTENT LEARNING ACTIVITIES RESOURCES EV ALUATION At the end of the module, the learner should be able to; I. Cognitive 1.1 Demonstrate knowledge of the diagnosis and management of common urologic disorders in the other surgical specialties. 1.2 Given a patient with urologic subspecialty problem, the resident should be able to formulate a comprehensive management plan.
Large Group Learning 1) Grand rounds 2) Pre and Postoperative Conferences 3} Mortality and Morbidity 4) Admitting rounds 5) Census 6) Lecturette Small Group Learning 1) Group Discussion 2) Group Tutorial 3) Brain Storming Independent Learning 1) Individual Study 2) Self Instructional Materials
Textbooks Of Urology -Campbells -Gillen & Waters adult & pediatric Urology -Smiths Urology Textbooks on Ultrasound & Basic Radiology
Practical Exam Written Exam
2. Psychomotor Perform or assist in common urologic surgical procedures
UROLOGY - hydrocoelectmy -nephrectomy for trauma -suprapubic cystostomy -cystolithotomy -orchidopexy/ orchiectomy for testicular torsion
Large Group Learning 1) Grand rounds 2) Pre and Postoperative Conferences 3)Mortality and Morbidity 4)Admitting rounds 5)Census 6) Lecture Perform previously listed procedures & assist in different urologic procedures
Direct observation 1)Rating scales 2) Checklists Incident reports Record review
3. Affective 1. Demonstrating professional behaviour in conducting evaluation of patient 2 Humility to accept own limitations & knows when to refer to TCVS specialist
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
Small Group Learning 1)Group Discussion 2)Group Tutorial 3)Brain Storming Independent Learning 1) Individual Study 2) Self Instructional Materials Small Group Learning 1) Role Playing 2) Simulation
1. Ward work 2. Ward work 3. ER consultation 4. OPD consultation 5. Operating Room Actual & Simulated Patients
Direct observation with attitude scale Patient Evaluation Anecdotal records Incident reports
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TRAUMA
Objective
Content
Teaching- Learning Activities
Resources
Evaluation
Given a patient, the learner should be able to :
Cognitive
1) Apply the principles of triage
2) Apply the principles of initial assessment and resuscitation
3) Formulate a comprehensive diagnostic and treatment plan including complications and rehabilitation
4. Apply the principles of 4.1Critical Care 4.2 Rational use of Antibiotics 4.3 Surgical Nutrition 4.4 Surgical Bacteriology
1. Trauma – Epidemiology & Prevention, Extrication & Trans- port, Triage, Patterns of Injury, Basic Life Support, Scoring System, Trauma Center 2. Perioperative Care of Traumatic Injuries 3.Trauma – Definitive Management of
Traumatic Injuries; Intensive care and rehabilitation;
critical care - Polytrauma
management - Mass casualty and disaster management
Large Group Learning 1) Grand rounds 2)Pre and Postoperative Conferences 3)Mortality and Morbidity 4)Admitting rounds 5)Census 6) Lecturette Small Group Learning 1) Group Discussion 2) Group Tutorial 3) Brain Storming Independent Learning 1) Individual Study 2) Self Instructional Materials
Basic Life Support ATLS Textbooks in Trauma Trauma Treatment Guidelines PJSS Nutrition Guidelines Surgical Infection Guidelines Basic Life Support
Written Exam Oral Examination Outcome Measures
2. Psychomotor
Given an actual patient, the learner should be able to perform the following :
2.1 Manage multiple organ system traumatic injuries
2.2. Apply critical care principles in the continuing care of the trauma patient.
2.3. Demonstrate techniques in the management of the polytrauma patient.
2.4. Participate in mass casualty and disaster management drills
Trauma - Multiple casualty Hospital/ER Triage - Multiple organ system injuries - Care of the Critically Injured patient
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation 4) Assisting in actual operations in trauma. Perform previously listed procedures & assist in different multiple organ system injuries procedures
Basic Life Support ATLS Textbooks in Trauma Trauma Treatment Guidelines PJSS Nutrition Guidelines Surgical Infection Guidelines
Practical exam Direct observation by 1) Checklist 2) Rating scale
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3. Attitude
3.1 During the session of simulated procedures & the actual operation, the learner should be able to demonstrate appropriate behaviors in a trauma situation.
3.2 Humility to recognize & accept own strengths & limitations and know when to ask help from a trauma surgeon.
1) Intellectual Integrity - practices intellectual honesty 2) Appropriate Bedside decorum 3) Team work – cooperate with other team members 4) Emotional maturity – stable even in most stressful situation 5) Empathy
I. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation II. Individualized Learning 1) Independent study of supplemental materials
Medico legal Books Bioethics Books Role Model Mentors Simulated & Actual Patients
Direct observation 1) Checklist 2) Rating Scale Incident Reports
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MINIMAL ACCESS SURGERY (Basic Laparoscopy & Diagnostic Laparoscopy)
Objective Content Teaching & Learning Activities
Resources Evaluation
Pre-operative preparation
A. Instrumentation Cognitive: After the session the learner should be able to: 1) Describe the operating room set-up 2) Identify the different laparoscopy instruments & its parts.
Psychomotor : After the session, the learner should be able to 1) Utilize the instruments correctly. 2) Prepare the scope & camera set up using the understanding of mechanism of focus, white balance & gain. B. Energy Sources Cognitive : After the session, the learner should be able to apply the principles of the different energy sources. Psychomotor : After the session, the learner should be able to identify the different energy sources in particular operative situation.
A. Operating room set- up B. Equipment for creating domain & energy sources C. Instruments 1) Access Instruments a) Veress needle b)Trocars-5 & 10 mm 2) Graspers, dissectors & scissors 3)Tissue approximation – needle drivers, staplers, clip appliers, fixation devices 4) Endoscopes a) 30 degree b) 0 degree (5 & 10 mm) 5) Organ retrieval bag 6) Suction & irrigator Energy sources 1) Electrosurgery 2) Lasers 3) Ultrasonic coagulating shears
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration
II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation Same as above I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation
1) Text book of laparoscopic procedure 2) Atlas of laparoscopic procedure 3) CD - Basic laparoscopy 4) PCS Advance Surgical skills manual 5) Library 6) Internet Same as above Same as above
1) Written examination 2) Oral Examination 3) OSCE 1) Checklist 2) Rating Scale 3)Anecdotal Record 1) Written examination 2) Oral Examination 3) OSCE 1) Checklist 2) Rating Scale 3) Practical Exam 4) OSCE 5)Anecdotal Record
Intra-operative Maneuvers Psychomotor After the session, the learner should be able to apply the following principles in both simulated laboratory & actual patient .
A. Camera operation & visual views B. Basic coordination skills C. Organ Exposure concepts of videoscopic
Same as above
I. Large Group Learning 1) Lecturette 2) Film Showing 3) Demonstration II. Small Group Learning 1) Small Group Discussion 2) Small Group Tutorial 3) Simulation
1) Text book of laparoscopic procedure 2) Atlas of laparoscopic procedure 3) CD-Basic Laparoscopy 4) PCS Advance surgical skills manual 5)Simulated operating room
exposure & laparoscopic skills 1) Port strategy 2) Use of gravity as retractor 3) Choices of visual views 4) Use of traction & counter traction 5) Partitioning of the abdomen 6)Motion parallax D. Assist in tissue approximation 1) Use of needle & needle holders 2) Knot tying techniques E. Specimen retrieval 1) Manuevers 2) Common extraction devices
Attitude After the session of simulated procedures & during the actual operation, the learner should be able to demonstrate appropriate behaviors .
1) Intellectual Integrity - practices intellectual honesty 2) Humility to recognize & accept own strengths & limitations and know when to ask help 3) Team work – cooperate with other team members 4) Emotional maturity – stable even in most stressful situation 5) Empathy
I. Small Group Learning 1) Small Group
Discussion 2) Small Group Tutorial 3) Preceptorial 4) Simulation II. Individualized Learning 1) Independent study of supplemental materials
1) Laparoscopy Textbooks 2) CD of laparoscopy procedures 3) Personal experiences of mentors ( lectures, film, books)
1) Direct observation 2) Rating Scale 3) Focus Group Discussion 4) Peer evaluation 5) Incident Reports
beliefs, values, ethics and sentiments 2. Behavior - the observable actions, responses, manners, activities and conduct of a
person 3. Brainstorming - intensive discussion in which spontaneous suggestions are uncritically
received. 4. Competency - behavior or performance that learners must be able to demonstrate,
with a defined level of proficiency or mastery. 5. Content - refers to the subject matter and topics to be learned. 6. Curriculum - a program of study, a series of planned activities intended to bring
about specific learning outcomes 7. Group discussion - discussion in which the topic & direction are controlled by
student or member. 8. Group Tutorial - discussion wherein topic & direction are given by the tutor but the
organization & content are determined by students. 9. Knowledge – refers to information, facts, concepts, ideas, principles, procedures and
processes one needs to acquire; it encompasses the cognitive domain of education.
10. Mentorship – developmental relationship between a more experienced mentor and a
less experienced partner referred as mentee or protégé.The mentor assumes multiple roles to bring enhancement of mentee’s professional, personal & psychological development. The mentor may be a role model, advocate, adviser, sponsor, developer of skills & intellect, facilitator & resource provider.
11. Objectives - the desired abilities, attributes, characteristics, level of performance to
be attained. 12. Preceptorship – a program involving a surgeon-trainee visiting an experienced surgeon’s
facility to observe and assist in a live surgery case & tour the facility. Includes:
Observation / assisting in live surgery Training on the safe & effective use of instruments
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Discussion of instrumentation & equipment organization while touring the facility
13. Proctorship – a program involving a surgeon-trainer visiting the trainee facility to assist with trainee’s first cases . The surgeon may or may not be able to scrub in on the case depending on the specific facility’s rules.
Includes: 1) Assistance in performing cases. 2) Training on the safe and effective use of instruments.
14. Psychomotor Skills – refers to the ability to perform techniques, procedures, processes,
and operations.
15. Small group learning - an educational process in which a group of individuals interact with one another to achieve educational objectives (critical thinking,
communication skills & ability to perform as a team members & leaders) & to maintain itself as a group.
16. Simulation - duplication of real situation in form of a problem & students adopt
appropriate roles or statuses. II. DEFINITION OF TERMS USED IN THE STANDARDIZED RESIDENTS’ EVALUATION A. Overall Clinical Competence
1. Database – history and physical examination findings complete and accurate 2. Diagnostic Tests – complete, exhaustive, cost-effective tests utilized and
interpreted correctly
3. Diagnosis, Judgement – correct diagnosis and rational clinical decisions 4. Treatment, Management – appropriate and efficient management of problems
6. Record Keeping – complete, accurate, comprehensive written records 7. After Care – post-operative management
B. Attitudinal Competence
1. Intellectual Integrity - demonstration of intellectual honesty 2. Moral/Ethical Values – demonstration of moral and ethical uprightness.
3. Reliability/Responsibility – performance of duty with efficacy, resourcefulness and
initiative.
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4. Relationship with Patients – establishment of good patient rapport, demonstration
of compassion
5. Study/Work Habits – demonstration of knowledge of required and supplemental readings.
6. Relationship w/ co-Health Workers & Society - professionalism, maintenance of a
healthy, respectful and motivated working relation with peers, respect for authority
7. Emotional Maturity Reaction to Stress – demonstration of stability and confidence
in common and stressful situations
8. Accepts own limitations – demonstrates ability to take the welfare of the patient into consideration; calls for assistance/help when need arises.
C. Technical Skills
1. Technical Dexterity – precision, smoothness and coordination of movements; execution of surgical maneuvers.
2. Intra-operative Judgment – ability to make precise decisions based on findings;
ability to anticipate problems that may arise. 3. Duration of Procedure – ability to complete a surgical procedure within a reasonable
and acceptable length of time.
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BOARD OF DIRECTORS
2006 2007 Arturo E. Mendoza, Jr., MD
Reynaldo M. Baclig, MD George G. Lim, MD Ramon S. Inso, MD
Joselito D. Almendras, MD Edgar A. Baltazar, MD Alex E.L. Cerrillo, MD
Giovanni A. De Los Reyes, MD Nilo C. De Los Santos, MD
Jaime B. Lagunilla, MD Ervin H. Nucum, MD
Enrico P. Ragaza, MD Roberto A. Sarmiento, MD Arnulfo D. Seares, Jr., MD Jackson D. Soriano, MD
President Vice-President
Secretary Treasurer Directors
Reynaldo M. Baclig, MD Ramon S. Inso, MD
Edgar A. Baltazar, MD Ervin H. Nucum, MD
Samuel R. Bacuteng, MD Esteban V. Belmes, MD Kenneth S. Chan, MD
Roberto M. de Leon, MD Giovanni A. de los Reyes, MD
Teodoro J. Herbosa, MD Jaime B. Lagunilla, MD Rex A. Madrigal, MD
Tomas J. Monteverde III, MD Alberto P. Paulino, Jr., MD
Enrico P. Ragaza, MD
PSGS COMMITTEE ON SURGICAL TRAINING
2005 2006 2007 Chairman Members Director – In-Charge
Gabriel L. Martinez, MD Shirard Leonardo C. Adiviso, MD Erwin B. Alcazaren, MD Hernan C. Ang, MD Michael C. Brillantes, MD Nelson F. Lim, MD Edgar T. Manalastas, MD Manuel A. Oliveros, MD Alfred N. Potenciano, MD Ariel S. Ramos, MD Vitus R. Talla, MD Wilfredo Y. Tayag, MD Ramon S. Inso, MD
Gabriel L. Martinez, MD Shirard Leonardo C. Adiviso, MD Hernan C. Ang, MD Michael C. Brillantes, MD Alfonso C. Danac, MD Nelson F. Lim, MD Romel T. Menguito, MD Ariel S. Ramos, MD Robert C. So, MD Ma. Concepcion C. Vesagas, MD Ramon S. Inso, MD
Gabriel L. Martinez, MD Shirard Leonardo C. Adiviso, MD Hernan C. Ang, MD Alfonso C. Danac, MD Nelson F. Lim, MD Romel T. Menguito, MD Robert C. So, MD Ma. Concepcion C. Vesagas, MD Ramon S. Inso, MD
