Colorectal PGY3 Friday, April 01, 2016

Stanford University General Surgery Residency Program Rotation Director: Andrew Shelton, MD

GOALS & OBJECTIVES SURGICAL ENDOSCOPY EXPERIENCE (As part of the Colorectal rotation)

The surgical endoscopy resident is a PGY-3 at Stanford while rotating on the Colorectal service at Stanford. He/she will perform pre-procedure work-up, including history and physical exams, with informed consents. He/she is expected to perform procedures with the colorectal faculty, Dr. Shai Friedland at the VA Livermore, and Dr. Goney Sandhu at the Freemont Surgical Center . This would include medical specialty boarded surgeons and gastroenterologists. Procedures to be performed by the resident include rigid proctoscopy, flexible sigmoidoscopy, colonoscopy with and without biopsy or polypectomy, esophagogastroduodenoscopy (EGD), and the placement of percutaneous endoscopic gastrostomy (PEG) tubes.

Upon completion of this two month endoscopy experience on the colorectal rotation, the resident should understand and have knowledge of:

♦ Indications and contraindications for colonoscopy ♦ Basic epidemiological and clinical presentation of colorectal cancer and the role of colonoscopy in screening and surveillance ♦ Bowel preparation for colonoscopy and the process of obtaining informed consent ♦ Handling, cleaning, and the disinfection of equipment used in colonoscopy ♦ Equipment needs and options for colonoscopy ♦ The proper use of conscious sedation and monitoring ♦ Techniques (intubation, biopsy, polypectomy, cautery, et.) of colonoscopy ♦ Basic endoscopic findings-recognition of normal and abnormal ♦ Complications of colonoscopy and their management ♦ Indications for EGD ♦ Indications for PEG placement ♦ Complications of EGD and PEG placement and their management

Approximately 1-6 colonoscopies are performed each week at Stanford colorectal. Dr. Friedland is available one day of each month with 6-8 colonoscopies per day. Dr. Goney Sandhu performs enough colonoscopies and EGDs to round out the requirements if one day a week is spent consistently over the two month period. It is our expectation that at the end of each two month experience, residents will perform between 30-50 colonoscopies and 10-20 upper endoscopies.

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Description The Colon and Rectal Surgery Rotation at SHC offers a broad experience in the care of complex patients encompassing benign and malignant diseases of the small bowel, colon, rectum, and anus

Goals The goal of the Colorectal Surgery rotation is to provide the R-3 resident with the means to: • Gain knowledge and experience in the inpatient and outpatient evaluation and management of patients with colorectal disease. • Develop procedural skills commonly required in the care of these patients. This will consist primarily of open abdominal operations, anorectal procedures, and some advanced laparoscopic procedures. • Refine colonoscopy skills • Experience and understand the day-to-day function of a complex surgical service. • When residents rotate at the Fremont Surgery Center, our goal is that they will perform rigid proctoscopies, flexible sigmoidoscopies, colonoscopy with and without biopsy or polypectomies, esophagogastroduodenoscopies (EGD), and the placement of percutaneous endoscopic gastrostomy (PEG) tubes.

Objectives

The Colorectal Surgery R-3 rotation has the following objectives: • The Chief resident has responsibility for the management of all inpatients on the service both ICU and ward in conjunction with the attending. The R-3 assumes this responsibility in the absence of the R-5 • The R-3 resident gains knowledge of colorectal surgery through discussion on rounds with the attending physician and also by independent reading and the assigned colorectal curriculum. This knowledge base includes basic, complex, open, and laparoscopic procedures as listed above. • The R-3 resident gains these advanced operative skills through pre-operative reading and preparation and by direct intra- operative teaching from the Colorectal attending. • The R-3 gains knowledge in basic epidemiological and clinical presentation of colorectal cancer and the role of colonoscopy in screening and surveillance by learning: • Bowel preparation for colonoscopy and the process of obtaining informed consent • Handling, cleaning, and the disinfection of equipment used in colonoscopy • Equipment needs and options for colonoscopy

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• The proper use of conscious sedation and monitoring • Techniques (intubation, biopsy, polypectomy, cautery, et.) of colonoscopy • Basic endoscopic findings-recognition of normal and abnormal • Complications of colonoscopy and their management • Indications for EGD • Indications for PEG placement • Complications of EGD and PEG placement and their management

R-3 residents can expect frequent teaching from members of the attendings. The R-3 resident and the attending will function together very closely in the OR, at the bedside and during formal and informal daily rounding sessions. The R-3 resident is a leader on the team when the R-5 is absent or otherwise occupied and should be able to run the entire service with the intern, nurses, and medical students. At the end of the rotation the R-3 resident should be able to diagnose, preoperatively assess, perform the operative procedure and manage the patient postoperatively, identifying and managing complications that may arise.

R-3 residents are evaluated in the 6 core competencies (Medical knowledge, Patient care, Interpersonal communication skills, Professionalism, Practiced based learning and Systems based practice) using specific web-based evaluation forms. An outline of core competencies with rotation objectives, instructional activities, and evaluations is below.

Specific Goals and Objectives for R-3 Residents GOALS R-3 OBJECTIVES INSTRUCTIONAL ACTIVITIES EVALUATION Core Competencies

Knowledge: • Gain experience in physical • Teaching by Weekly feedback by To acquire and apply examination, diagnostic imaging attending faculty. attendings and Rotation knowledge of studies, pre-operative evaluation evaluation by each colorectal established and and risk assessment, peri-procedural • Independent attendings. evolving basic and management of deep venous reading applied clinical thrombosis anticoagulation, and (https://stanford.medhub.com) sciences that relate to post-operative patient monitoring. • Daily rounds and the practice of conferences colorectal surgery including M&M, and the other areas Grand Rounds and

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already listed. Core Course, GI Conference, and colorectal teaching conconference.

GOALS R-3 OBJECTIVES INSTRUCTIONAL ACTIVITIES EVALUATION Core Competencies Patient Care: • Evaluate, triage, staff and manage all Attends twice daily rounds Weekly feedback by other To provide inpatient colorectal surgery with the resident team and residents and nurses as well as compassionate, consultations at SHC in conjunction with once daily with the the Colorectal attendings and appropriate and the PGY 5 resident attending. Runs rounds in two-month rotation evaluation effective care patients in • Evaluate and correct complete directed the absence of the R-5 by each colorectal surgery the listed categories. history and physical examinations on attending. colorectal surgery patients. Review all Preoperative and post- (https://stanford.medhub.com) accompanying clinical and image- operative monitoring of based information regarding their other residents and patients, and develop an independent student work and notes. management plan appropriate for each patient. Teaching during rounds • Manage patients intra-operatively with and conferences. the Attending Surgeon. Providing feedback to the others on the Colorectal Team.

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Effective Interpersonal • Instruct interns and medical students on Twice daily rounds with the Weekly feedback by and Communication basic general surgical techniques in the Colorectal Surgery Team. Colorectal Attending. skills: surgical simulation center. Residents must • Deliver teaching sessions for interns and (https://stanford.medhub.com) communicate in a way students either before or after rounds on that leads to effective a weekly basis. information exchange of • Provide family members an update of a colorectal surgery care patient’s condition. plan to patients, their • Discusses appropriate peri-operative families, and professional concerns with team & consultants. associates. • Works effectively with team members (attending, interns and NP) to communicate care plan and discuss with attendings.

GOALS R-3 OBJECTIVES INSTRUCTIONAL ACTIVITIES EVALUATION Core Competencies Practice based learning • Serve as team leader as the R-5. Works Rounds with the Colorectal Weekly feedback by other and improvement: effectively with team inpatient census, Team and attending residents and nurses as well as In order to improve reporting requirements, team schedules, surgeon. the Colorectal attendings and patient care practices, R- vacation coverage, daily clinical two-month rotation evaluation. 5residents must be able assignment, patient management tasks and Daily Conferences. (https://stanford.medhub.com) to critically evaluate their morbidity and mortality conference. own performance as well • Identify complications and determine their as appraise and impact on recovery. Present them at the incorporate clinical M&M conference. scientific evidence. • Use information technology to rapidly assimilate current medical literature as it relates to patient care.

Professionalism: • Learn to manage complex patient problems Twice daily rounds with the Weekly feedback by other Residents must show a specifically related to relaying information to Colorectal Team. residents and nurses as well as

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commitment to families regarding unexpected outcomes in the Colorectal attendings and professional a quaternary care hospital. two-month rotation evaluation responsibilities, • Learn to interact with a wide range of by each Colorectal attending. adherence to ethical patient age ranges. (https://stanford.medhub.com) principles and sensitivity • Learn to interact with multiple subspecialty to diversity. groups in consultation as well as multi- disciplinary conferences. • Displays appropriate demeanor, even in adverse situations. Acts with sensitivity and responsiveness to patient’s culture, age, gender and disabilities.

GOALS R-3 OBJECTIVES INSTRUCTIONAL ACTIVITIES EVALUATION Core Competencies Systems-based Practice: • Act as an organizational problem-solver for Twice daily rounds with the Weekly feedback by other An R-5 resident must be Colorectal surgery patients. Understand how Colorectal Team and daily residents and nurses as well as able to demonstrate an care for patients affects the hospital’s ability rounds with surgery the Colorectal attendings and awareness of and to deliver patient care. attendings. two-month rotation evaluation responsiveness to the by each Colorectal Surgery system of health care • Understands how care practice affects attending. and the ability to staffing and health care costs. (https://stanford.medhub.com) effectively call on system resources to provide optimal care.

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