General Surgery Sault Ste Marie Site

Rotation Orientation and Objectives Junior Resident (PGY1-2)

Introduction Welcome to your General Surgery Rotation in SSM. SAH (Sault Area Hospital) is a Secondary Care referral center with a large volume of core and complex surgical cases. There are a wide variety of supporting specialties and subspecialty surgical disciplines here at SAH allowing our rotations to fulfill much of the Royal College training requirements for both Surgical Foundations and the General Surgery core competencies. Team Structure We have elected to divide the group of General Surgeons here at into teams. Whenever possible, each team will have at least one resident assigned to it. The purpose of this structure is to allow collaboration and education to be delivered in a structured fashion between staff, residents and students. It is the expectation that residents round on all inpatients (both those who are admitted under the surgeon as well as active consults) prior to the commencement of the day’s activities. The most senior resident on the team is responsible for organizing the timing and format of rounds with the junior members of the team, and to communicate in a timely fashion all pertinent issues to the staff surgeons of that team. This element will be evaluated as part of the communicator, collaborator and manager/leader roles of the CanMeds framework . (http://www.royalcollege.ca/portal/page/portal/rc/canmeds/framework) Staff surgeons may elect to round with you in the morning, or communicate to you a different time to round on their patients. It must be stressed that any significant change in a patient’s status should be communicated to the staff surgeon as soon as possible. Based on the Royal College requirements for rotation objectives, it is expected that each resident attend at least one of the following on a weekly basis:

One OR day

One endoscopy day (suggested) One ambulatory clinic or office day

Failure to comply with this framework will constitute a “below expectations” grade on the overall rotation. We will be instituting a passport system to track compliance with days. Junior residents are also expected to collaborate with the nursing staff, in particular on 3A, which is our surgical unit. Many of the nurses here are very experienced and knowledgeable about the perioperative care of our general surgical patients, and it would be wise partake of their wisdom and experience. Residents are also expected to attend the emergency department when on-call or directed by the staff surgeons he or she is working with, to see patients at the request of the emergentologists. PGY-1 residents will be on second call for all emergency and in-hospital calls, with either the staff or senior resident taking first call. Based on the graded professional responsibility, PGY-2 residents will be considered for first call for the emergency department based on staff assessment of their readiness to take on this role. Whether a resident is paged directly by the emergency room (PGY-2) or directed to attend a patient in the department or on the ward after the staff surgeon was contacted will be an arrangement agreed upon between the staff surgeons on a team and the resident. Call Residents are expected to take call one in three nights on average. Resident call is home call. PAIRO guidelines regarding frequency of call, post-call days off, and resident wellness will be adhered to strictly. Residents are responsible for generating an appropriate and fair call schedule and submitting it to the site diector in a timely manner at the beginning of the rotation. Identification Badges & Pagers Both of these will be arranged on your first day in the Medical Affairs office. When on duty, residents are expected to carry and respond to their pagers at all times. Service Rounds Service rounds for General Surgery are held every Wed from 7:00-8:00 AM The topics for rounds vary from week to week, but include morbidity and mortality rounds, interesting cases, business, and topic presentations.

Residents are expected to present on a topic of their choice at least ONCE during their rotation to fulfill the medical expert, health advocate and scholar CanMeds roles. The timing of this will be arranged with the site chief. Scholarly Activities Operating on patients is a privilege, not a right. Residents are expected to know the history of patients being operated on prior to coming to the OR, as well as relevant anatomy and surgical rationale. Residents are expected to read around cases and demonstrate appropriate and progressive knowledge in the preoperative, intraoperative and postoperative care of surgical patients. The roles of medical expert, scholar, and health advocate are intricately tied into this. This will be an integral component a resident’s midterm and final evaluation. As we have few resident numbers, typically junior residents will be first assist or principal operators on cases with the staff. More complex cases usually will have a senior resident or another staff in the operating room. The technical proficiencies outlined in the medical expert roles below will be fulfilled by this model to achieve competencies appropriate for junior residents, and Surgical Foundations. In addition to presentations at service rounds, residents are expected to attend all program educational activities and teaching sessions as laid out by the program director. Clinical duties are NOT to take precedence over these, and failure to attend these sessions will potentially result in a failure of a rotation. Education is a priority and will be taken seriously by both residents and staff. Medical Students The role of and level of responsibility given to senior medical students assigned to medical services is changing. Currently, medical students are not allowed to write orders or prescribe medications independently. They are, however, allowed to assess patients independently while under the supervision of a physician. As such, part of a resident’s responsibility while on service will be to assist in managing the directed education of medical students and helping to coordinate the tasks they perform in conjunction with the staff surgeons. This is true for both senior and junior residents. Professionalism Professionalism is a key component to effective surgical and medical practice, and is a core skill and attribute that will be assessed throughout a resident’s rotation. It is expected that residents comply with the SAH code of conduct outlined on the intranet website. In general, residents (and all medical professionals) should demonstrate consideration and respect for their colleagues and members of the

healthcare team, while expecting the same from others. The hospital should be an enjoyable and safe place to work, free of intimidation, abuse, or persecution. The staff surgeons here are committed to seeing residents both treat and be treated with respect at all times. Evaluation There will be a midterm and final evaluation for all residents in a timely fashion. The midterm evaluation should occur roughly at the midpoint of the rotation, and should identify strengths and weaknesses of the resident in order to allow ample time to build on his or her successes and correct his or her areas of weakness. It is the responsibility of both the resident and staff surgeons to ensure these evaluations are conducted in a timely manner and in person. If a resident is having difficulty arranging a meeting for an evaluation, he or she must contact the program director immediately. Evaluation of residents will be conducted in an objective fashion utilizing the NOSM evaluation spreadsheet and CanMeds framework on one45. The goals and objectives outlined in this document will be utilized in the assessment of residents. Ward and Inpatient Care It is expected that the most senior resident assigned to each team organize daily morning rounds on all active inpatients with the other medical learners assigned to the team. There are times when this responsibility will fall to a PGY-1 or PGY-2. Individual staff surgeons may elect to round with you in the morning or organize an alternative time to see and discuss inpatients with residents. It is expected that these rounds are initiated and completed such that members of the team have ample time to arrive at their appropriate daily activities before these activities commence. On post-call days, residents are still expected to conduct these rounds. Once these are complete, a resident is responsible for signing out his or her patients to another resident or their staff surgeons, fulfilling the communicator and collaborator roles. If other specific objectives are expected of the resident, they will and must be communicated to the resident during the rotation with ample time to allow for effective evaluation based on these objectives. If this is not done, this objective cannot be considered during a resident’s mid-term or final evaluation.

MEDICAL EXPERT Perioperative and Postoperative Management

1. Participate and conduct effective management of patients in the perioperative phase, including management of common post-operative issues such as electrolyte abnormalities, fluid shifts, cardiorespiratory complications, ileus, etc.

2. Identify critical surgical complications and initiate appropriate interventions for issues such as surgical site infections, bowel anastamotic dehiscences, bleeding, intraabdominal abscesses, etc.

3. Identify and initiate appropriate discharge planning for postoperative patients.

4. Collaborate with allied health professionals in a collegial manner to achieve the above goals and effective care of surgical patients.

5. Become familiar with the concept of pre-operative risk assessment, prehabilitation, optimization of comorbidities, and consideration of alternative treatment strategies for patients in the ambulatory setting.

6. Adequately arrange follow-up for patients upon discharge from hospital to ensure appropriate longitudinal care for active or anticipated health issues.

Breast - Knowledge

1. Develop a framework for the management of benign breast disease including fibroadenomas, gynecomastia, fibrocystic disease of the breast, and breast cysts.

2. Develop an algorithm for the workup of common breast complaints such as breast mass, nipple discharge, breast pain, abnormal imaging,

3. Understand the role of serial imaging, biopsy, and surgical intervention of high-risk benign breast lesions such as atypical ductal hyperplasia, atypical lobular hyperplasia, complex sclerosing lesions, etc.

4. Develop a framework for the management of in-situ and invasive mammary carcinoma, including the necessity of involvement of non-surgical disciplines such as medical oncology and radiation oncology.

5. Advocate for appropriate screening measures for patients with both average and above-average lifetime risk for breast cancer.

6. Become familiar with discussions around breast reconstruction, including methods and timing.

7. Demonstrate an understanding of risk factors for breast malignancies, including tools used to assess risk (e.g. Gail Model)

8. Have a brief understanding of atypical malignancies of the breast such as Phyllodes’ tumours, lymphomas, and sarcomas.

9. Understand the concepts behind unique breast malignancy scenarios such as Paget’s Disease, locally-advanced breast cancer, inflammatory breast cancer, and breast cancer during pregnancy.

10. Become familiar with the decreasing role of axillary node dissection in the contemporary management of breast cancer

11. Understand the surgical options for management of breast carcinomas, including lumpectomy, mastectomy, skin-sparing mastectomy, nipple-sparing mastectomy, wire-localized lumpectomy, toilet mastectomy and modified radical mastectomy, and be able to discuss their appropriate use in case scenarios with faculty

12. Be able to explain the concept, anatomy and physiology of a sentinel lymph node biopsy.

13. Be able to discuss the indications, contraindications, limitations and side-effects of adjuvant chemotherapy, radiation therapy and hormonal therapy

14. Understand the indications, contraindications and limitations of neoadjuvant chemotherapy.

15. Become familiar with palliative therapies for patients with metastatic breast cancer.

Breast – Technical

1. Understand the importance of patient positioning and surgical site marking during operations on the breast.

2. Be able to appropriately prepare and drape the breast surgical patient in the operating room

3. Develop appropriate subcutaneous flaps utilizing appropriate use of retraction and countertraction.

4. Be able to dissect the breast tissue off of pectoralis/fascia without violating muscle.

5. Be able to aid in the identification of the sentinel lymph node. Appendix - Knowledge

1. Display appropriate understanding of the pathophysiology of acute appendicitis.

2. Understand the role of clinical signs and symptoms to facilitate timely diagnosis of patients with acute appendicitis.

3. Display an appropriate use of ancillary tests in aiding the diagnosis of acute appendicitis.

4. Understand the concept of missed appendicitis and its appropriate management.

5. Demonstrate appropriate post-operative management of patients after appendectomy including timely discharge.

6. Obtain an understanding of the types of and management of tumours of the appendix.

7. Begin an understanding of the unique management scenarios of patients with appendicitis, including the pediatric patient, the patient with multiple previous surgeries, and patients with chronic or missed appendicitis who fail to resolve with medical therapy.

Appendix – Technical 1. Display an ability to adequately prepare a patient with appendicitis for an

emergency operation, including preoperative cardiorespiratory assessment, intravenous fluid resuscitation, and use of timely antibiotics.

2. Be able to position a patient adequately for an open appendectomy and laparoscopic appendectomy.

3. Conduct the initial incision to gain access to the appendix via an open approach.

4. Be able to adequately expose and resect the appendix utilizing an open approach.

5. Be able to adequately close an open appendectomy incision. 6. Be able to establish pneumoperitoneum safely during a laparoscopic

appendectomy 7. Be able to safely and atraumatically handle both the appendix and the tissues

surrounding the appendix using laparoscopic instruments. 8. Be able to resolve pneumoperitoneum and close laparoscopic incisions

following a laparoscopic appendectomy. Biliary - Knowledge

1. Understand the pathophysiology of calculous biliary disease and the entities of biliary colic, acute cholecystitis, gallstone pancreatitis, choledocholithiasis, and cholangitis.

2. Appropriately triage and manage patients with biliary colic in an outpatient setting, including preoperative optimization techniques such as risk-factor modification.

3. Be able to initiate preoperative management of patients presenting with emergent conditions of the biliary tree such as acute cholecystitis, choledocholithiasis, cholangitis, and gallstone pancreatitis.

4. Understand the role of therapeutic endoscopy and display appropriate collaborative efforts in arranging such procedures for patients with the aforementioned entities.

5. Recognize complications of cholecystectomy, including bile leak, bile duct injury, bleeding, and abscess, and initiate resuscitative treatment.

6. Demonstrate an initial understanding of the preoperative assessment and indications for operative intervention in patients with biliary dyskinesia, acalculous cholecystitis, bile duct malformations, gallbladder cancer, gallbladder polyps, cholangiocarcinoma, and sclerosing cholangitis.

Biliary – Technical 1. Conduct appropriate preoperative preparation for a patient undergoing a

cholecystectomy, including a surgical checklist, stewardship over antibiotic use, appropriate patient positioning and establishment of a sterile field.

2. Be able to perform a laparotomy to expose the gallbladder in preparation for an open cholecystectomy

3. Be able to perform the steps required to expose the gallbladder during an open cholecystectomy.

4. Be able to perform a dissection of the gallbladder off of the gallbladder fossa (top-down approach) during an open cholecystectomy.

5. Be able to adequately close a laparotomy incision to complete an open cholecystectomy.

6. Safely establish pneumoperitoneum during a laparoscopic cholecystectomy 7. Safely place laparoscopic ports in an appropriate location to conduct a

laparoscopic cholecystectomy. 8. Be able to expose and retract the gallbladder appropriately to facilitate

dissection of the hepatocystic triangle during a laparoscopic cholecystectomy.

9. Be able to safely dissect cystic artery and duct for patients without inflammation or adhesions during a laparoscopic cholecystectomy.

10. Be able to dissect the gallbladder off of the gallbladder fossa during a laparoscopic cholecystectomy.

11. Be able to safely resolve pneumoperitoneum and close incisions during a laparoscopic cholecystectomy.

Colon and Rectum - Knowledge

1. Understand and articulate the anatomy and physiology of benign colonic disorders such as inflammatory bowel disease, diverticular disease, angiodysplasia, ischemic colitis, infectious colitis, solitary rectal ulcer syndrome, rectal prolapse, and obstructed defecation.

2. Display an understanding of the non-surgical and surgical techniques used in the management of the aforementioned benign colonic disorders, and understand the indications for when these are to be used.

3. Develop a framework for the investigation and management of non-neoplastic colorectal disorders such as colitis, inflammatory bowel disease, diverticular disease, colonic volvulus, and functional bowel disorders.

4. Understand the role of pre-operative staging in the management of colorectal neoplastic processes.

5. Describe in detail the current guidelines for, and types of, colorectal cancer screening in Ontario.

6. Display stewardship in the use of colonoscopy for patients in the screening setting.

7. Understand and describe the indications for urgent or emergent endoscopy for conditions such as sigmoid volvulus, stenting of neoplastic strictures, lower GI bleeding, and colonic pseudo-obstruction.

8. Understand the endoscopic and surgical management of pre-neoplastic and neoplastic polyps, and when each method is appropriately used.

9. Understand the increasing role of laparoscopy in the operative management of neoplastic and non-neoplastic colorectal disorders, and when it is

appropriate to utilize laparoscopic techniques to perform segmental colorectal resection.

10. Obtain an understanding of emerging techniques in the management of neoplastic conditions of the rectum and anus such as Transanal Endoscopic Microsurgery (TEMS), Transanal total mesorectal excision (TATME).

11. Display an ability to initially manage emergent conditions of the colon and rectum such as large bowel obstruction, perforation, lower GI bleeding, volvulus, pseudo-obstruction, refractory infectious or inflammatory colitis, and toxic megacolon.

12. Understand the need to collaborate with other medical specialties (gastroenterology, oncology, palliative care) to facilitate optimal management of patients with the aforementioned disorders.

13. Demonstrate appropriate application of the ERAS pathway to facilitate effective patient care, manage resources, and advocate for patients’ overall health and recovery from colorectal surgery.

14. Understand the concept of prehabilitation for patients awaiting elective colorectal surgery in an outpatient setting.

15. Conduct an appropriate preoperative outpatient assessment for a patient requiring elective colorectal resection, including risk modification strategies, pre-anaesthetic consults, bowel preparation, and discussion of operative risks.

16. Describe in detail the indications for neoadjuvant therapy in patients with locally-advanced rectal cancer, as well as their appropriate pre-operative and post-therapy assessment.

17. Understand the increasing role of metastectomies in patients with metastatic colorectal cancer.

18. Describe palliative therapies for patients with inoperable colorectal cancer (stenting, chemotherapy, ablative therapy, radiotherapy, symptom management).

19. Be able to describe the concept of a total mesorectal excision and its’ importance to the management of rectal cancer.

Colon and Rectum – Technical

1. Conduct appropriate same-day preparation of the patient presenting to the operating room for elective colorectal resection, including appropriate conduct of a surgical safety checklist, insertion of foley catheter, DVT prophylaxis, appropriate and evidence-based use of antibiotics, and patient positioning.

2. Adequately prepare and drape a patient undergoing a colon resection. 3. Adequately prepare and drape a patient undergoing a sigmoid or rectal

resection. 4. Safely and efficiently enter the abdomen utilizing an appropriate incision for

a given open segmental colon or rectal resection.

5. Conduct a systematic exploratory laparotomy for regional or distant metastases during an open segmental colon or rectal resection for malignant disease.

6. Safely mobilize the retroperitoneal portions of the colon to medialize the organ during an open segmental right, left, and sigmoid resection, sub/total colectomy.

7. Be able to proficiently mobilize the transverse colon and enter the lesser sac, when appropriate, during an open segmental colon resection.

8. Be proficient in ligature and suture ligature of mesenteric vessels during a segmental colon or rectal resection.

9. Conduct an appropriate closure of the abdomen upon completion of an open segmental colon or rectal resection.

10. When appropriate, be able to mature an ostomy. 11. Be able to conduct a flexible sigmoidoscopy and colonoscopy for diagnostic

purposes.

Anus - Knowledge

1. Demonstrate an understanding of the pathophysiology, anatomy, work-up and surgical management of benign anal diseases such as abscesses, fistulae-in-ano, fissures, solitary rectal ulcer, nercrotizing perianal soft tissue infections, hemorrhoids, fecal incontinence, rectal prolapse, and pruritis ani.

2. Demonstrate an understanding of the multidisciplinary management strategies for malignant processes of the anus including anal canal cancer, anal margin cancer, Bowen’s disease, Paget’s disease, and anal melanoma.

3. Understand the anatomy of the anal canal as it relates to sensation, function, and continence.

4. Be able to counsel patients regarding non-surgical treatment of benign anal diseases such as fecal incontinence, rectal prolapse, pruritis ani, hemorrhoids, and fissures.

5. Be able to conduct a complete assessment of a patient presenting with the above conditions in an ambulatory setting.

Anus – Technical

1. Demonstrate an ability to properly prepare a same-day patient for anal canal or anal margin surgery, including conducting a surgical checklist, appropriate use of antibiotics, and patient positioning.

2. Be able to conduct an anoscopy and Baron Ligation of hemorrhoids. 3. Be able to conduct all steps in a traditional operative hemorrhoidectomy

proficiently. 4. Demonstrate proficiency in identifying fistulae-in-ano intraoperatively. 5. Demonstrate an ability to perform a fistulotomy and/or insertion of draining

setons, when appropriate, for fistulae-in-ano. 6. Be able to safely debride tissues involved in necrotizing soft tissue infections

of the perineum.

7. Be able to conduct an excisional biopsy of lesions in the anal margin. Stomach and Duodenum - Knowledge:

1. Demonstrate an understanding of the anatomy and physiology of the stomach and duodenum and apply it to the medical and surgical management of peptic ulcer disease.

2. Develop an appropriate and applicable differential diagnosis for the patient presenting with an upper gastrointestinal bleed.

3. Understand the surgical considerations and techniques of managing patients with a perforated duodenal or gastric ulcer, including management of the “difficult duodenum”.

4. Demonstrate complete proficiency in the resuscitation and preoperative preparation of patients presenting emergently with perforated peptic ulcers.

5. Understand the multidisciplinary management of patients diagnosed with resectable gastric adenocarcinoma, including seminal clinical trials demonstrating the efficacy of adjuvant chemotherapy and chemoradiotherapy in the neoadjuvant and adjuvant setting.

6. Understand the role of neoadjuvant treatment of patients with gastric adenocarcinoma.

7. Recognize the role of palliative techniques and supports in patients with unresectable adenocarcinoma of the stomach.

8. Display an awareness of the multimodal management of gastrointestinal stromal tumours of the stomach.

9. Display competency in evaluating and managing patients presenting with an undifferentiated duodenal mass.

10. Be aware of rare conditions of the stomach and duodenum such as neuroendocrine tumours of the stomach/duodenum, lymphoma, duplication cysts, gastric volvulus, etc.

11. Be able to recognize patients presenting emergently with gastric volvulus or incarcerated paraesophageal hernias and involve and demonstrate an ability to initiate involvement of appropriate surgical subspecialties to assist in the management of these entities.

12. Be able to describe the types of bariatric surgery procedures and their potential complications including marginal ulceration, internal hernia, dumping syndrome, afferent limb syndrome, and anastomotic dehiscence.

Stomach and Duodenum – Technical 1. Be able to conduct a diagnostic upper endoscopy for patients presenting with

an upper GI bleed. 2. Be able to prepare a patient presenting for elective or emergent surgery for

diseases of the stomach and duodenum, including conducting a surgical checklist, stewardship over antibiotic use, insertion of foley catheters, DVT prophylaxis and patient positioning/preparation.

3. Create and resolve access incisions for both laparoscopic and open operations for the stomach and duodenum.

4. Safely mobilize the omentum for use as a Graham Patch for a perforated peptic ulcer.

5. Safely and proficiently perform an open or percutaneous endoscopic gastrostomy tube (PEG).

Small Intestine - Knowledge

1. Demonstrate a thorough understanding of the anatomy and physiology of the small intestine, including blood supply, uptake of nutrients, absorption of bile salts, etc..

2. Demonstrate a complete understanding of pathophysiologic conditions of the small intestine, including small bowel obstruction, inflammatory bowel disease of the small intestine, Meckel’s diverticulum, and small bowel neoplastic disease.

3. Initiate appropriate resuscitative management for patients presenting emergently with a small bowel obstruction.

4. Be proficient in recognizing and initiating nonsurgical management of patients with complications of inflammatory bowel disease of the small intestine, including strictures, perforation, and fistula.

5. Be able to quickly recognize patients with complications from a Meckel’s diverticulum, including inflammation, bleeding, and obstruction.

6. Understand the etiology, epidemiology, and unique medical and psychosocial needs of patients with short gut syndrome and intestinal failure; have a general understanding of surgical and nonsurgical methods used to manage these patients.

7. Be able to describe in detail potential short and long-term complications of morbid obesity surgery.

Small Intestine – Technical

1. Be able to independently prepare a patient presenting for same day elective surgery on the small intestine, including unique considerations for laparoscopic techniques (patient positioning, bed type and securing devices), conducting a surgical safety checklist, etc.

2. Be proficient in gaining access to the abdomen through a laparotomy or for minimal-access surgery.

3. Be able to manipulate the small bowel adeptly and atraumatically either during open or laparoscopic surgery.

4. Demonstrate independent proficiency in the placement of feeding jejunostomy tubes.

5. Be able to effectively close pathologic or iatrogenic enterotomies using a single or double layer technique.

6. Be able to conduct, with assistance, a Meckel’s diverticulectomy.

7. Be able to conduct, with assistance, all components of a small bowel resection.

8. Be able to conduct a stapled side-to-side anastomosis with assistance from faculty.

Trauma – Knowledge

1. Be able to independently conduct all components of a primary and secondary survey for a critically-injured trauma patients according to ATLS protocols, and employing universal precautions during resuscitative efforts.

2. Be able to effectively lead a trauma team in the conduct of a primary and secondary survey.

3. Be proficient in identifying life-threatening findings in the primary survey that require immediate intervention as outlined in the ATLS protocols.

4. Be able to effectively identify patients in need of urgent/emergent operative intervention for life-threatening traumatic injuries,

5. Be able to secure appropriate adjuncts to a primary and secondary survey (imaging, consults, investigations) to aid in the management of clinically-stable trauma patients.

6. Be able to discuss the epidemiology of trauma mechanisms in Canada, and identify at-risk populations to help aid in educational efforts and trauma prevention.

7. Understand the role of damage control laparotomy and temporary abdominal closure, and apply this principle when appropriate to critically-injured trauma patients.

Trauma – Technical

1. Be able to independently perform trauma-bay interventions as defined by the ATLS guidelines, which include intubation, surgical airways, chest tubes, central lines, arterial lines, and FAST.

2. Be aware of trauma-bay interventions that require greater expertise and supervision such as pericardiocentesis, diagnostic peritoneal lavage, and fasciotomies.

3. Be proficient in adequately preparing the operating room for a trauma patient, and conducting a preoperative preparation of said patient.

4. Be able to independently conduct a trauma laparotomy, and assist in the management of the intraoperative findings.

5. Be able to conduct, with supervision, a trauma thoracotomy. 6. Assist in temporary abdominal closure techniques, when appropriate.

Skin and Melanoma - Knowledge

1. Understand the risk factors, clinical signs and relevant historical details for patients presenting with non-melanoma skin cancers

2. Be able to describe a variety of common benign integumentary diseases (pathophysiology, epidemiology and clinical presentation) such as pilonidal sinus, nevus, keratosis, verruca vulgaris, and extraintestinal manifestations of inflammatory bowel disease

3. Understand in detail the epidemiology, etiology, presentation and work-up of all subtypes of melanoma.

4. Be aware of adjuvant therapies currently available for patients with melanoma, and their relative indications for use.

5. Have an understanding of methods used to reconstruct integumentary deficits or defects (primary closure techniques, flaps, grafts)

6. Be able to actively resuscitate a patient presenting with skin surface burns, and initiate protective treatment based on published guidelines (ATLS, ACS).

Skin and Melanoma – Technical

1. Be able to complete all parts of an excisional biopsy of a benign skin lesion. 2. Be able to conduct all aspects of an excision of a biopsy-proven non-

melanoma skin cancer 3. Be able to conduct a wide local excision with appropriate margins for a

melanoma. 4. Assist in the conduct of an axillary or inguinal sentinel lymph node biopsy. 5. Be able to perform various methods of primary closure of skin defects,

appropriately selected for the clinical scenario. Hernia – Knowledge

1. Demonstrate a detailed knowledge of the anatomy of the inguinal and femoral canals.

2. Be able to describe the epidemiology, etiology, and risk factors for inguinal and femoral hernias in the pediatric and adult populations

3. Be able to describe methods of repair of inguinal and femoral hernias, including tissue repair techniques and techniques utilizing prosthetic mesh, as well as their indications.

4. Be able to actively resuscitate and prepare a patient with an incarcerated or strangulated inguinal/femoral hernia for an emergent corrective procedure.

5. Be able to recognize the signs of a bowel obstruction due to an incarcerated hernia.

6. Acquire a thorough understanding of the various abdominal wall hernias, including their anatomy, epidemiology, etiology and clinical presentation: umbilical, epigastric, incisional, spigellian, lumbar.

7. Have a detailed knowledge of the anatomy of the abdominal wall and its layers.

8. Be able to describe the principle of component separation. Hernia – Technical

1. Acquire the ability to perform a modified Lichtenstein repair for a non-incarcerated inguinal hernia with minimal guidance from faculty

2. Be able to perform a tissue repair for a femoral hernia with assistance from the attending surgeon

3. Be able to repair an umbilical hernia with or without mesh with minimal guidance from staff.

4. Be able to perform a repair of a ventral incisional hernia with mesh with assistance from staff.

5. Assist in the various tissue repairs used to repair strangulated inguinal/femoral hernias.

Intrinsic Roles Professionalism

1. Conduct oneself in a manner that is respectful to patients, families, and other health professionals.

2. Understand that conflicts do occur in the workplace, and display an ability to resolve these in a cordial, respectful and collaborative manner, with the assistance of a senior resident or faculty.

3. Abide by the code of conduct outlined on the internal website 4. Attend to all duties and activities in a punctual manner. 5. Participate in clinical activities in a non-intoxicated condition. 6. Answer all pages in a timely manner. 7. Provide direct supervision of medical students on service by ensuring

appropriate direct supervision for clinical rounds, and aiding in the scheduling of their daily responsibilities.

8. Be able to identify your own limitations both within and outside the operating room, and voice any concerns regarding a request to overstep these limitations to the senior resident or faculty supervisor.

9. Be respectful of the expertise of other allied health professionals. 10. Utilize social media responsibly, respecting confidentiality of both patients,

colleagues and other health care workers. Health Advocate

1. Using an evidence-based approach, demonstrate an ability to select and implement the appropriate, patient-centered treatment for patients for conditions commonly encountered on this service, such as breast cancer, colon cancer, and melanoma.

2. When collaborating with other medical services and allied health professionals, ensure that other services understand the medical and non-medical needs of the patient, as well as the role they are to play in the care of said patient.

3. Ensure that patients under your care are managed appropriately by all medical services involved in their care, and discuss with your supervisor when this condition is not met.

4. Understand the needs of local hospitals needing to send patients SAH for emergent/urgent referrals and advocate help the clinical team facilitate care of these patients.

5. Be aware and respectful of the unique needs of the local First Nations communities, and demonstrate an ability to advocate for their needs while under our care (diabetes education, increased risk of surgical site infections, decreased awareness of screening for breast and colorectal cancer).

6. Advocate in the ambulatory setting for evidence-based screening and preventative methods for common general surgical oncology conditions – breast cancer, colon cancer, and melanoma.

Scholar

1. Continue to demonstrate a contemporaneous grasp of the surgical literature as it applies to the evolving care of the surgical patient, outlined by the topics detailed in the overall goals and objectives of surgical foundations.

2. Participate in NOSM General Surgery’s longitudinal model for research – continue to develop and build on current research projects, and strive for new opportunities to answer clinical questions emerging during rotations.

3. Attend and participate in journal club, and complete tasks assigned by the site director in this regard.

4. Attend all service rounds (except business rounds) and multidisciplinary cancer rounds.

5. Complete a presentation during your rotation on a topic encountered during the rotation with an evidence-based review of the relevant literature, to be presented during service rounds (assigned by the site director).

6. Contribute to the environment of scholarly activity within the clinical setting by teaching medical students during clinical duties.

7. Fulfill responsibilities for presentations during Friday Morning Resident rounds.

Communicator

1. In addition to the roles outlined in the objectives above, demonstrate an ability to effectively discuss medical issues, both emergent and elective, with other medical professionals and services efficiently and respectfully.

2. Attend and participate, unless excused, in surgical rounds. 3. Make nursing staff aware of emerging changes in a patient’s status, as well as

the overall goals and treatment plans for patients on a daily basis. 4. Communicate any changes in clinical status of patients to the senior resident

or attending physicians in a timely manner.

5. Ensure handover of patients to fellow residents and attending staff is conducted in a thorough manner, with appropriate handover of any pressing or emerging issues.

6. Dictate notes on patients, when assigned to do so by attending physicians or senior residents, in a thorough and timely manner.

7. Answer all pages in a timely manner. 8. Participate in family discussions regarding a patient’s clinical status with the

senior resident and/or attending physicians. 9. If unable to attend to clinical duties, inform both the program coordinator,

site director, and (if present) other residents on the service regarding your absence.

Collaborator

1. In addition to the many of the objectives outlined above, attend both multidisciplinary cancer conferences and surgical service rounds

2. Display an effective ability to utilize other services in the appropriate, patient-centered management of surgical patients on the service.

3. When interacting with patients and care-providers on other services, demonstrate an ability to integrate your specific goals of the care of this patient (as defined by the attending faculty) with the overall management of the patient.

4. Discuss overall goals of patients, including effective discharge planning, with allied health professionals and the charge nurse on the surgical ward, especially with our charge nurses

5. Attend to the needs of the surgical patients admitted to the ICU. 6. Under the direction of the senior resident or attending physician, enlist the

assistance of other clinical services to help meet the overall health needs of the patients under your care.

Manager/Leader

1. Display competency in effective and appropriate allocation of resources, in the outpatient, ward, and emergency room setting, when treating patients, such as use of imaging, and requests for procedures.

2. Understand the prioritization of surgical cases, both on elective lists, and when on-call on the emergency list.

3. Understand the financial implications of inappropriate resource allocation and use in contemporary patient management.

4. Display an effective ability to prioritize tasks related to patient care, and complete them in a timely manner.

5. Participate in the assignment of tasks for medical students, and off-service junior residents on the service.

6. Understand what resources are in limited supply (nuclear medicine, MRI, operating room time) and effectively allocate these resources to patients

based on their need, in concert with attending physicians and senior residents.

7. Begin to understand the increasing need for physicians in leadership and decision-making positions in both the hospital and regional settings.

8. Demonstrate an ability to achieve a healthy work-life balance, utilizing protected time for academics and post-call days.

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