UNIVERSITY OF MANITOBA DEPARTMENT OF SURGERY RESIDENCY PROGRAM

BLUE BOOK Table of Contents

TABLE OF CONTENTS

Section 1: Administrative & Organization 1.1: Goals and Objectives 1.2: Administrative Structure 1.3: Educational Structure/Organization 1.4: Curriculum 1.5: Program Teaching Sites 1.6: Principles of Surgery Training 1.7: Chief/Senior Administrative Resident

Section 2: Learning Objectives (Mandatory Rotations) 2.1: General Surgery 2.2: General Surgery – A-Service 2.3: General Surgery – B-Service 2.4: General Surgery – Community Surgery 2.5: General Surgery – Gold Service: Trauma & Acute Care 2.6: General Surgery – Green Service: Surgical Oncology 2.7: General Surgery – Orange Service: General & Hepatobiliary Surgery 2.8: Anatomy 2.9: Critical Care 2.10: Emergency 2.11: Endoscopy 2.12: Internal Medicine 2.13: Pediatric Surgery 2.14: Vascular Surgery

Section 3: Learning Objectives (Elective Rotations) 3.1: Anesthesiology 3.2: Cardiac Surgery 3.3: Gastroenterology 3.4: Neurosurgery 3.5: Orthopedic Surgery 3.6: Plastic Surgery 3.7: Radiology 3.8: Surgical Infectious Diseases 3.9: Thoracic Surgery 3.10: Urology

Section 4: Other Components of Program 4.1: Academic & Scholarly 4.2: Career Planning 4.3: Evaluation of Faculty 4.4: Evaluation of Resident Performance 4.5: Evaluation of Services/Rotations 4.6: Master of Science in Surgery Program 4.7: Research Activities 4.8: Resident Resources 4.9: Stress Management

Page 0.0.1 Table of Contents

Section 5: Forms Christmas/New Year’s Request Form Education Leave Request Form General Surgery CanMEDS Anatomy Evaluation Form General Surgery CanMEDS Evaluation From General Surgery CanMEDS Mid-Rotation Evaluation Form Vacation Request Form

Page 0.0.2

Section 1: Administrative & Organization Administrative & Organization – Goals and Objectives

1.1: GOALS AND OBJECTIVES

DEFINITION OF GENERAL SURGERY The specialty of General Surgery embraces the principles and techniques of safe, effective, ethical and compassionate care of the whole person of any age and is the parent of all surgical specialties. The general surgeon is an eclectic specialist whose practice involves the alimentary tract, trauma and critical care, endocrine and breast diseases, cancer surgery and endoscopy. By virtue of training, special interest or circumstances, the practice of general surgery may be narrowly focused or may encompass diseases or injuries affecting virtually any body system. General surgical practice includes expertise in communication and collaboration, teaching and research, health care management and advocacy and continuing professional development.

OVERALL GOAL OF THE PROGRAM Upon completion of training in the General Surgery Residency Training Program at the University of Manitoba, the resident is expected to be a competent specialist capable of assuming a consultant’s role in general surgery (see Objectives of Training and Specialty Training Requirements in General Surgery RCPSC). As the scope of General Surgery is very broad and the types of practice will vary considerably, the Program allows the resident to pursue one of the following career paths: • Academic surgery • Community surgery

In order to achieve competency in General Surgery, the resident must achieve the following: • Knowledge and expertise in clinical and operative management of diseases of the alimentary tract, breast and endocrine systems, trauma and critical care, general surgical oncology and ambulatory care • Mastery of technical skills of open and minimal access abdominal, endocrine, breast, trauma, soft tissue and abdominal wall surgery and endoscopy • Effective clinical judgment and decision-making in managing general surgical problems based on sound principles and fundamentals

The Program emphasizes that the resident must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to the practice of General Surgery, including research methodology and data presentation and analysis. The General Surgery Residency Training Program at the University of Manitoba has developed and distributed specific learning objectives for each rotation/educational experience within the Program. The learning objectives are functional for the residents and the teaching faculty. Furthermore, the learning objectives are reflected in resident evaluations and in the planning and organization of the Program. The Program embraces the Royal College of Physicians and Surgeons of Canada CanMEDS competencies of the specialist physician and these are reflected in the overall and rotation-specific learning objectives (see diagram below).

Page 1.1.1 Administrative & Organization – Goals and Objectives

Page 1.1.2 Administrative & Organization – Administrative Structure

1.2: ADMINISTRATIVE STRUCTURE

PROGRAM DIRECTOR The Program Director is responsible for the overall conduct of the General Surgery Residency Training Program (also referred to as the “Program” in this document). The Program Director is responsible to the Head of the Department of Surgery, the Director of Postgraduate Surgical Education and the Associate Dean of Postgraduate Medical Education of the University of Manitoba. The Program Director, assisted by the General Surgery Postgraduate Committee is responsible for: • Development and operation of the Program such that it meets the standards for accreditation by the Royal College of Physicians and Surgeons of Canada (RCPSC) • Selection of candidates for admission to the Program • Evaluation and promotion of residents in the Program • Maintenance of an appeal mechanism for residents • Provision of counselling and career planning for residents • Intervention to deal with resident problems such as those related to stress • Review (resident opinion taken into consideration)) of the quality of the educational experiences and the resources available, including: o Assessment of each component of the Program to ensure that the learning objectives are being met o Assessment of resource allocation o Assessment of teaching o Faculty evaluation

The Program Director advocates for the resident and maintains an “open-door policy” with respect to resident concerns or problems. The resident is encouraged to bring any matters of concern to the Program Director for timely intervention. Matters that cannot be adequately addressed by the Program Director are referred to the appropriate parties for definitive management. The resident can choose an individual other than the Program Director to advocate on his/her behalf. There is a Program Coordinator, responsible to the Program Director in each institution participating in the Program. There is active liaison between the Program Director and the Program Coordinators.

GENERAL SURGERY POSTGRADUATE COMMITTEE The General Surgery Postgraduate Committee (Committee) assists the Program Director in planning, organization and supervision of the Program. The Committee includes the Program Coordinators, Service Chiefs, representatives from each major component of the Program and resident representatives from each level of training elected by their peers. The Committee meets every two months (five times per year) and minutes are kept. During the meetings, faculty/resident interaction and discussion take place in an open and collegial atmosphere.

SURGICAL EDUCATION OFFICE The Surgical Education Office functions as the headquarters of the General Surgery Residency Training Program. The office of the Coordinator-Surgical Education Programs and the secretarial and support staff are located there. The resident should contact the Surgical Education Office if he/she is encountering any difficulties and the Coordinator (or designate) will assist in facilitating a timely resolution of the problem(s).

Page 1.2.1 Administrative & Organization – Educational Structure/Organization

1.3: EDUCATIONAL STRUCTURE/ORGANIZATION

The General Surgery Residency Training Program at the University of Manitoba is organized into mandatory and elective surgical and non-surgical rotations whereby the resident must acquire the requisite knowledge, clinical and technical skills and attitudes and must integrate all of the CanMEDS roles to become a specialist general surgeon. Each resident enrolled in the Program has an equal opportunity to take advantage of those elements of the Program best able to meet his/her educational needs. Furthermore, the Program encourages teaching and learning in an environment which promotes resident safety and is free of intimidation, harassment and abuse. The Program is structured for the resident to achieve the learning objectives as follows:

COGNITIVE (KNOWLEDGE) The resident is encouraged to: • Maintain a regular program of reading selected textbooks and journals • Attend academic/educational sessions, including the General Surgery Academic Half-Day (mandatory) • Attend the monthly General Surgery Journal Club (mandatory) • Utilize the amenities of the General Surgery resource rooms • Attend scientific meetings • Arrange for an attending surgeon to be his/her mentor

PSYCHOMOTOR (CLINICAL AND TECHNICAL SKILLS)

¾ Clinical Skills During the years of training in the Program, the resident is immersed in the clinical setting, developing and improving his/her skills in disease recognition and in appropriate investigation and management of general surgical disorders. He/she develops the ability to apply knowledge of anatomy, physiology and pathology to the clinical situation and to treat the whole patient. He/she is given increasing professional responsibility according to his/her level of training, ability and experience. The clinical learning objectives and expectations depend on the resident’s level of training as follows: During the first three years in the Program the resident is participates as a member of the general surgical teaching units. The resident gains experience through specific unit assignments, including: • Emergency Department where the PGY-1, PGY-2 or PGY-3 resident learns resuscitation, assessment and management of patients with surgical emergencies and discuss these with a more senior resident and/or attending surgeon • Surgical Clinic where the PGY-1, PGY-2 or PGY-3 resident assesses new patients with elective or urgent surgical illness and assess postoperative patients with respect to their recovery and progress and discusses this with a more senior resident and/or attending surgeon • Hospital Ward where the PGy-1, PGY-2 or PGY-3 resident learns the preoperative and postoperative management of hospitalized patients and discusses this with a more senior resident and/or attending surgeon

Page 1.3.1 Administrative & Organization – Educational Structure/Organization

¾ Technical Skills It is expected that the General Surgery resident will develop technical skills (including intraoperative decision-making and surgical judgment) in a graded manner. Ultimately the resident is expected to perform general surgical procedures competently, safely and independently. Some of the more complex surgical procedures may require further training beyond the five-year Program. The General Surgery resident should develop basic technical skills during the first two years of the Program as follows; • Handling of the scalpel (power/precision) • Creation and closing of surgical incisions • Mastering knot-tying skills and understanding suture materials • Mastering the principles of gentle tissue handling • Mastering the principles of surgical assisting • Mastering surgical stapling skills and understanding stapling devices • Mastering the techniques pertaining to hemostasis • Comprehending the techniques of intestinal and vascular anastomosis • Understanding the principles of surgical drains • Mastering open /laparoscopic general surgical procedures appropriate for his/her level of training

The basic technical skills are taught in the Surgical Skills Courses scheduled during the Program (see Academic and Scholarly Content of the Program), and in the clinical setting. Some of the basic skills, such as knot-tying are mastered with practice outside the clinical setting. The General Surgery resident develops mastery of the major general surgery procedures (open, minimal access and endoscopy) during the more senior years in the Program. During the final year of training, the General Surgery resident should progress to performing substantial parts of most general surgical procedures independently or with assistance only and should be able to teach more junior residents the less complex technical procedures. The General Surgery resident must maintain a surgical/endoscopic procedure log during his/her training. The log assists the resident for certification/credentialing purposes and assists the Program Director in evaluating the resident’s progress and in ensuring that he/she has attained an increasing level of professional responsibility. The log is compiled and maintained in an online format. The resident must write preoperative/operative notes on all patients on whom he/she has operated. Furthermore, the resident who performs the substantial part of the operation must dictate the operative report in a timely manner.

AFFECTIVE (ATTITUDE/PROFESSIONAL CONDUCT) The General Surgery Training Program at the University of Manitoba requires that the resident attain and demonstrate the learning objectives with respect to attitude and professional conduct. These include: • Communication skills • Collaboration with other health care workers • Management skills to balance patient care, learning needs, outside activities and personal life • Health advocacy to improve individual and societal health • Scholarly activities, including teaching and research • Professional/ethical conduct

The affective objectives are met through role modeling within the Program and through academic and educational seminars and courses.

Page 1.3.2 Administrative & Organization – Educational Structure/Organization

SERVICE/EDUCATION RELATIONSHIP The success of the General Surgery Residency Training Program relies on the understanding by the resident and the faculty that there are educational and service components which must interact harmoniously. The Program strongly supports the concept that resident education is paramount. However, surgical education is in many ways dependent on service responsibilities. At no time will a resident’s educational schedule be disrupted or altered to satisfy service requirements unless the move is advantageous to the resident’s education and the resident agrees to it. The General Surgery Residency Training Program Academic Half-Day takes place on Wednesday afternoon. All General Surgery residents are excused from clinical/service duties during this time (protected) and attendance is mandatory. If the resident at any time feels that his/her educational activities are being infringed upon in the interest of service, he/she should discuss this with the Chief of the service, the Program director or the Chief resident.

ON-CALL DUTIES On-call schedules are arranged by the Chief resident in General Surgery. Presently the on-call frequency averages one night in three (maximum). This frequency corresponds to the principles established by an agreement between the Professional Association of Residents and Interns of Manitoba (PARIM) and the Winnipeg Regional Health Authority (WRHA). When a resident is on vacation the on-call schedule is modified accordingly without increasing the average frequency of on-call of the remaining residents. Occasionally a resident on a rotation without on-call duties is requested by the Chief resident in General Surgery to assist with on-call duties (maximum frequency one night in seven) on a service where one of the residents is on vacation or absent for other reasons. This must occur on a voluntary and collegial basis. The Program strongly supports the concept of the resident leaving the service early the day after being on- call (post-call). Appropriate patient hand-over must be completed, urgent duties must be completed and co-residents must be notified.

MOONLIGHTING Although moonlighting is not prohibited, it is not encouraged. Scholarly and recreational pursuits by the resident are more important. Moonlighting probably interferes with the resident’s educational activities and is generally felt to be counter-productive. The Program Director will prohibit the resident from moonlighting if there is a concern with respect to his/her academic performance (CAGS exam results, for example).

Page 1.3.3 Administrative & Organization – Curriculum

1.4: CURRICULUM

The General Surgery Residency Training Program at the University of Manitoba consists of five years of general surgical training (optional six years with the Master of Science Degree in Surgery). The Program is organized such that the resident is given increasing professional responsibility, under appropriate supervision, according to his/her level of training, ability and experience on clinical rotations. The academic and scholarly aspects of the Program complement the resident’s clinical experience and prepare the resident to fulfill all of the roles of the specialist General Surgeon (see Objectives of Training and Specialty Training Requirements in General Surgery RCPSC). Evaluation of the resident’s performance is made regularly, and this contributes to the final assessment to sit the certification examination in General Surgery. The first two years of the Program are structured as Principles of Surgery (formerly called Core Training in Surgery), which consists of broad-based clinical rotations in surgical and non-surgical areas and Core Surgery lectures which supplement the clinical experience and follow the RCPSC objectives (see Objectives of Core Training in Surgery and Outline of the Contents for the Examination on the Principles of Surgery). It is expected that the General Surgery resident will write the Principles of Surgery Examination (POS) during the second year of training (PGY-2). The third and fourth years of the Program consist of general surgical experience and exposure to endoscopy, vascular surgery and pediatric surgery. Community surgery and other electives are offered as well. The resident’s curriculum is designed to meet his/her individual requirements for future surgical practice. Those residents interested in an academic career may choose the Master of Science Degree in Surgery Program for an additional year of research experience (after PGY-2 or after PGY-3). During the final year in the Program, the resident functions as the Senior/Chief resident, where he/she is entrusted with the responsibility for preoperative, operative and postoperative care, including the most difficult general surgical problems. The Senior/Chief resident is in charge of a general surgical unit and is directly responsible to the attending staff surgeons in the unit.

Page 1.4.1 Administrative & Organization – Program Teaching Sites

1.5: PROGRAM TEACHING SITES

Several hospitals participate in the General Surgery Residency Training Program at the University of Manitoba. These include: • Major teaching hospitals • Community Hospitals • Other

MAJOR TEACHING HOSPITALS There are two major teaching hospitals in Manitoba and these provide extensive clinical educational experience for the resident.

¾ Health Sciences Centre This is Manitoba’s largest health care complex and functions as the major referral centre for trauma and acute surgical illness (General Hospital). It is the major referral centre for pediatrics and pediatric surgical illness (Children’s Hospital). The general surgery sites at the Health Sciences Centre include:

General Hospital ¬ Trauma and Acute Care Service (Gold) • Provides training in trauma and acute care surgical management • Attending surgeons are on-site on a twenty-four hour basis • Formal walk rounds with the attending surgeon • Ambulatory clinic experience ¬ Hepatobiliary/Gastrointestinal Service (Orange) • Major emphasis on gastrointestinal surgery • Strong liaison with gastroenterology/endoscopy unit • Formal rounds • Ambulatory clinic experience ¬ Surgical Oncology Service (Green) • Major emphasis on head and neck and other malignancies • Multidisciplinary management of complex oncology cases • Ambulatory clinic and Breast Health Centre experience • Liaison with CancerCare Manitoba

Children’s Hospital ¬ Pediatric Surgery Unit • Exposure to most major pediatric surgical disorders (except cardiac surgery) • Formal rounds and teaching sessions • Ambulatory clinic experience

¾ St. Boniface General Hospital St. Boniface General Hospital is a major referral centre for complex general surgical problems, excluding multiple trauma. There is a major emphasis on colorectal, breast and minimal access general surgery. The surgical skills laboratory facility is located at St. Boniface General Hospital.

Page 1.5.1 Administrative & Organization – Program Teaching Sites

A-Service General Surgery • Emphasizes most general surgical disorders • Major minimal access general surgery component • Major gastrointestinal/colorectal surgery component • Major breast surgery component • Liaison with endoscopy unit/gastrointestinal bleed team • Formal rounds and audit • Ambulatory clinic and Breast Health Centre experience

B-Service General Surgery • Emphasizes most general surgical disorders • Major gastrointestinal/colorectal surgery component • Liaison with endoscopy unit/gastrointestinal bleed team • Formal rounds and audit • Ambulatory clinic experience

COMMUNITY HOSPITALS Several urban and rural community hospitals in Manitoba allow the General Surgery resident elective training in community general surgical practice. These include: • Brandon Regional Health Centre in Brandon, Manitoba • Dauphin Regional Health Centre in Dauphin, Manitoba

OTHER COMMUNITY HOSPITALS The resident has the opportunity to arrange an elective at one of the following community hospitals: • Seven Oaks General Hospital in Winnipeg • Victoria General Hospital in Winnipeg • Concordia Hospital in Winnipeg

OTHER TEACHING SITES

¾ Northwestern University Hospital This hospital, located in Chicago, Illinois provides elective training in organ transplantation.

¾ Winnipeg Regional Health Authority Breast Health Centre This facility provides a multidisciplinary milieu for the resident to learn the assessment and management of breast disorders

¾ Churchill Health Centre This complex, located in Churchill, Manitoba has a liaison with the Northern Medical Unit at the University of Manitoba. The General Surgery resident may be invited (if circumstances permit) by the attending surgeon to accompany him/her to Churchill for training and experience in northern medicine and surgery.

Page 1.5.2 Administrative & Organization – Principles of Surgery Training

1.6: PRINCIPLES OF SURGERY TRAINING

During the PGY-1 and PGY-2 the General Surgery resident learns the Principles of Surgery pertinent to general surgical training. This period of training consists of mandatory and elective clinical rotations and a structured lecture series based on the learning objectives for the Principles of Surgery as specified by the Royal College of Physicians and Surgeons of Canada. Training for the Principles of Surgery follows the recommendations of the RCPSC so that the Program Director for the General Surgery Residency Training Program and the General Surgery Postgraduate Committee are responsible for developing the Principles of Surgery curriculum/rotation-specific objectives and for evaluation of the General Surgery resident. During this period of training, the General Surgery resident remains the responsibility of the Program Director for General Surgery. The Director of the Principles of Surgery Training oversees the academic component of core training for residents of all surgical programs. He/she receives input, guidance and support from the individual program directors. It is expected that the General Surgery resident will write the Principles of Surgery Examination (POS) in the PGY-2 academic year. The following reference is important for the resident to review: • Objectives of Core Training in Surgery and Outline of Contents for the Examination on the Principles of Surgery (RCPSC)

Page 1.6.1 Administrative & Organization – Chief/Senior Administrative Resident

1.7: CHIEF/SENIOR ADMINISTRATIVE RESIDENT

CHIEF RESIDENT There will be a Chief resident nominated by his/her peers and approved by the Program Director for the academic year. The Chief resident will have the authority and responsibility for overseeing the administrative and teaching duties of all residents in the Program, including Senior Administrative residents. All residents report to the Chief resident. The Chief resident reports to the Program Director.

CLINICAL RESPONSIBILITIES The Chief resident is assigned to a specific general surgical unit and will oversee the more junior residents in an advisory capacity, including: • Assignment of appropriate clinical cases to the more junior residents to encourage graded responsibility in the operating room • Assisting the more junior residents in the management of difficult or complex cases

The Chief resident assumes overall responsibility for all patients on the general surgical unit with respect to: • Investigations and planning of care • Preoperative preparation • Intraoperative management/operative report • Postoperative care/rounds/notes • Discharge planning

The Chief resident attends the Service Rounds and ambulatory care clinics on his/her assigned service regularly. The Chief resident will take regular on-call duties.

ADMINISTRATIVE RESPONSIBILITIES The Chief resident is responsible for the following: • Convening of meetings of the residents in the Program to discuss issues of concern • Attending the meeting of the General Surgery Postgraduate Committee (or he/she may send a delegate if unable to attend) • Ensuring that a resident representative to PARIM council is elected from among the residents in the Program • Ensuring that there is resident representation on Program, departmental and faculty committees for matters pertaining to education • Ensuring that there is resident representation on hospital committees concerning issues such as audit and mortality review • Acting as liaison between the residents in the Program and faculty members for purposes of communication, mediation and conflict resolution • Coordination and preparation of the on-call schedules • Serving on probation committees

Page 1.7.1 Administrative & Organization – Chief/Senior Administrative Resident

• Assisting in the approval of conference leave for residents • Ensuring that the resident resource rooms and their contents are maintained

EDUCATIONAL RESPONSIBILITIES The Chief resident is responsible for the following: • Teaching of more junior residents and physicians in training • Coordination of orientation of new residents and physicians in training

SENIOR ADMINISTRATIVE RESIDENT Final-year residents in the Program on services or at sites remote from the Chief resident are designated Senior Administrative residents. They report to the Chief resident and assist him/her.

CLINICAL RESPONSIBILITIES The Senior Administrative resident has the same clinical duties as the Chief resident

ADMINISTRATIVE RESPONSIBILITIES The Senior Administrative resident will: • Function as the Chief resident if he/she is absent for any reason • Maintain regular communication with the Chief resident and discuss issues of concern • Prepare the on-call schedules under the supervision of the Chief resident

EDUCATIONAL RESPONSIBILITIES The Senior Administrative resident will: • Assist in the education of more junior residents and physicians in training • Assist in the orientation of new residents and physicians in training

Page 1.7.2

Section 2: Learning Objectives

(Mandatory Rotations) Learning Objectives (Mandatory) – General Surgery

2.1: GENERAL SURGERY

PREAMBLE The following learning objectives apply generally to any of the rotations/services in General Surgery participating in the General Surgery Residency Training Program at the University of Manitoba. However, each rotation or service has its particular area of subspecialty, expertise or interest, with a greater emphasis on certain aspects of the learning objectives and a lesser concentration on others (e.g. Trauma and Acute Care (Gold) Service; Surgical Oncology (Green) Service). Furthermore, surgical services may change their emphasis, depending on the faculty assigned to the service.

GENERAL OBJECTIVES Upon completion of training, the General Surgery resident is expected to be a competent specialist in General Surgery, capable of assuming a consultant’s role. The resident must acquire a thorough knowledge of the theoretical basis of General Surgery, including its foundations in the basic medical sciences and research. The resident must demonstrate the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies of the General Surgeon, including gender-related, cultural and ethnic perspectives.

SPECIFIC OBJECTIVES At the completion of training, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert General Surgeons possess a defined body of knowledge and procedural skills which are used to collect and interpret data, make appropriate clinical decisions and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date and (whenever possible) evidence-based, ethical and cost-effective clinical practice and effective communication in partnership with patients, other health care providers and the community. The role of the medical expert is central to the function of the general surgeon and draws on the competencies included in the role of communicator, manager, health advocate, collaborator, scholar and professional. At the completion of training, the General Surgery resident will be able to:

Function effectively as a consultant, integrating all of the CanMEDS roles to provide optimal, ethical and patient-centred general surgical care • Effectively perform a consultation, including the presentation of well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care professional • Identify and appropriately respond to relevant ethical issues arising in patient care • Effectively and appropriately prioritize professional duties when faced with multiple patients and problems • Demonstrate compassionate and patient-centred care • Recognize and respond to the ethical dimensions in medical decision-making • Demonstrate medical expertise in situations other than patient care (e.g. presentations, medico-legal cases, etc.)

Page 2.1.1 Learning Objectives (Mandatory) – General Surgery

Establish and maintain clinical knowledge, skills and attitudes appropriate to the practice of General Surgery • Apply knowledge of the clinical, socio-behavioral and fundamental biomedical sciences relevant to General Surgery • Apply lifelong learning skills to implement a personal program to keep up-to-date and enhance areas of professional competence • Contribute to the enhancement of quality care and patient safety, integrating the available best evidence and best practices

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Surgical Anatomy and Embryology • Surgical Physiology • Surgical Pathology • Clinical Pharmacology o Analgesics; sedatives; anesthetic agents o Respiratory and cardiovascular o Gastrointestinal o Antibiotics o Antineoplastic agents o Antiemetic agents • Medical Problems in the Surgical Patient o Preoperative assessment o Preparation for specific operative interventions o Antimicrobial prophylaxis o Anticoagulation and thromboembolic prophylaxis o Corticosteroid management o Diabetes management • Conduct of a Surgical Procedure o General principles o Specific operative interventions • Postoperative Care o Prevention and treatment of postoperative infections o Management of cardiac/hypertensive complications o Management of postoperative thromboembolic complications o Management of postoperative pulmonary complications o Management of endocrine/metabolic problems (e.g. diabetes) o Management of fluid and electrolyte/renal problems • Wound Management and Healing • Sepsis and Surgical Infections • Hemostasis and Use of Blood Products • Epidemiology and Biostatistics • Trauma and Thermal Injuries o Metabolic response to critical illness/trauma o Multi-organ dysfunction o Trauma assessment and resuscitation (ATLS principles) o Triage and transport o Airway management in trauma o Shock in trauma o Injuries to the central nervous system o Injuries to the face and jaw o Injuries to the neck o Injuries to the chest/diaphragm/great vessels o Abdominal trauma (including major vascular injuries)

Page 2.1.2 Learning Objectives (Mandatory) – General Surgery

o Injuries to the urogenital tract o Musculoskeletal injuries o Injuries to the extremities (vascular; bone; soft tissues) o Burns and other thermal injuries • Fluid Management and Acid-Base Problems • Metabolic and Nutritional Care • Hemodynamics/Oxygen Transport/Shock • Transplantatation and Implantation o Immunology and transplantation biology o Specifics of transplantation techniques • Cancer o Principles of neoplasia o Diagnosis and staging o Therapeutic options: surgery; chemotherapy; radiation; other o Principles of chemotherapy o Principles of radiation oncology • Legal and Ethical Issues in General Surgery • Radiology for the General Surgeon o Plain x-rays o Mammography/stereotactic breast biopsy o Contrast studies and interventional radiology o Computerized tomography o Ultrasound o Magnetic resonance imaging o Nuclear medicine studies o Positron emission tomography (PET) • Laboratory Medicine for the General Surgeon o Hematology o Biochemistry o Microbiology o GI laboratory studies: esophageal manometry and pH; anorectal manometry o Vascular laboratory studies ¬ Specific Disease Entities • Skin and Soft Tissue o Pressure sores o Hidradenitis suppurativa o Pilonidal sinus disease o Cysts o Neoplasms, including melanoma and Kaposi’s sarcoma • Breast o Fibrocystic condition/simple cyst/complex cyst o Fibroadenoma and other benign neoplasms/phylloides tumour o Abscess/mastitis o Nipple discharge o Gynecomastia o Mastodynia o Evaluation of dominant mass/thickening o Atypical epithelial hyperplasia o LCIS/DCIS o Inherited breast cancer o Paget’s disease o Invasive breast cancer o Male breast cancer o Breast reconstruction

Page 2.1.3 Learning Objectives (Mandatory) – General Surgery

• Head and Neck o Lip lesions o Oral cavity lesions o Salivary gland lesions: inflammatory; infectious; neoplastic o Thyroid disorders: goiter; neoplastic;inflammatory o Parathyroid disorders: metabolic; neoplastic • Veins and Lymphatics o Thromboembolic disorders o Venous insufficiency o Varicose veins o Lymphatic disorders • Esophagus and Diaphragm o Motility disorders o Gastroesophageal reflux disease o Barrett’s esophagus o Perforation/Mallory-Weiss tear o Diverticulum o Esophageal cancer o Caustic injury o Varices o Diaphragmatic hernia o Diaphragmatic injury/rupture • Stomach and Duodenum o Gastritis/gastropathy o Peptic ulcer/H. pylori o Volvulus o Diverticula o Menetrier’s Disease o Bezoars o Postgastrectomy syndromes o Neoplasms: benign; malignant o Arteriovenous malformations; GAVE; watermelon stomach o Dieulafoy’s lesion o Varices o Gastroparesis o Duodenal diverticulum o Crohn’s disease o SMA syndrome • Small Intestine o Crohn’s disease o Celiac disease o Enteritis/enteropathy o Neoplasms: benign; polyps; malignant o Small intestinal fistulas o Diverticulum; Meckel’s o Blind loop syndrome o Pneumatosis o Short bowel syndrome/intestinal failure o Intestinal obstruction o Motility disorders/ileus o Mesenteric ischemia

Page 2.1.4 Learning Objectives (Mandatory) – General Surgery

• Colon and Rectum o Mechanical obstruction o Paralytic ileus/pseudo-obstruction o Inflammatory bowel disease: Crohn’s; ulcerative colitis o Ischemic colitis o Infectious colitis o Pseudomembranous colitis o Radiation enterocolitis o Diverticular disease o Megacolon o Volvulus: sigmoid; cecal o Polyps and polyposis syndromes o Neoplasms: benign; malignant; HNPCC o Solitary rectal ulcer o Rectal prolapse o Constipation/motility disorders/functional disorders o Pneumatosis o Angiodysplasia/vascular malformations o Colorectal bleeding o Foreign bodies of the rectum o Rectal trauma • Anus o Neoplasms: benign; malignant o Anal infections/sexually-transmitted disease o Condyloma/AIN o Hemorrhoids o Fistula o Fissure o Pruritis ani o Incontinence o Levator ani syndrome • Appendix o Appendicitis o Neoplasms: benign; malignant o Crohn’s disease • Liver and Portal System o Abscess o Cyst o Neoplasms: benign; malignant o Portal hypertension and its manifestations • Biliary Tract/Gallbladder o Gallstone disease and its manifestations o Choledochal cyst o Sclerosing cholangitis o Cholangiohepatitis o Neoplasms: benign; malignant o Hemobilia • Pancreas o Pancreatitis: acute; chronic o Cyst o Periampullary neoplasms: benign; malignant o Endocrine disorders of the pancreas

Page 2.1.5 Learning Objectives (Mandatory) – General Surgery

• Spleen o Operative indications for splenectomy o Hypersplenism o Neoplasms: benign; malignant o Metabolic disorders o Erythrocyte disorders o Autoimmune disorders o Vascular disorders o Cyst o Infections/abscess o Splenosis o Hematologic effects of splenectomy o Postsplenectomy sepsis • Peritoneum and Retroperitoneum o Peritonitis o Abscess o Ascites o Adhesions o Retroperitoneal fibrosis o Retroperitoneal hematoma o Neoplasms/pseudomyxoma o Internal hernia • Omentum and Mesentery o Omental torsion o Omental cyst o Mesenteric vascular disease o Neoplasms: benign; malignant • Abdominal Wall/Hernia o Rectus sheath hematoma o Neoplasms: benign; malignant o Inguinal hernia o Femoral hernia o Umbilical hernia o Ventral hernia o Spigelian hernia o Lumbar hernia o Obturator hernia o Richter’s hernia o Parastomal hernia • Adrenal o Cushing’s syndrome o Adrenogenital syndrome o Primary aldosteronism o Addison’s disease o Estrogen-secreting neoplasms o Pheochromocytoma o Neuroblastoma o Ganglioneuroma o Cyst o Metastatic disease • Other Clinical Problems o Gastrointestinal bleeding o Intestinal obstruction o The acute abdomen o Morbid obesity/bariatric surgery

Page 2.1.6 Learning Objectives (Mandatory) – General Surgery

Perform a complete and appropriate assessment of a patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective management plan in collaboration with a patient and his/her family • Demonstrate effective, appropriate and timely application of preventive and therapeutic interventions relevant to the practice of General Surgery • Ensure appropriate informed consent is obtained for therapies • Ensure patients receive appropriate end-of-life care

The PGY-1 resident will be able to: • Perform many of the above clinical skills • Correctly diagnose the common general surgical problems • Formulate management strategies; will often require corroboration or modification by more senior individual

The junior resident will be able to: • Perform the above clinical skills • Complete the data gathering process • Correctly diagnose most general surgical problems • Formulate management strategies; will require corroboration or modification by more senior individual

The senior/chief resident will be able to: • Perform the above clinical skills • Complete the data gathering process efficiently • Correctly diagnose all general surgical problems • Formulate management strategies completely, even for complex or difficult problems

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the practice of General Surgery • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the practice of General Surgery • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base (T-Res log) of all operative procedures performed as a General Surgery resident

Page 2.1.7 Learning Objectives (Mandatory) – General Surgery

Residents at all levels of training will be able to: • Apply knowledge and expertise to performance of technical skills relevant to the practice of General Surgery • Assist in the operating room • Master the techniques of gentle tissue handling

The PGY-1 resident will be able to: • Initiate the process of technical skills development by assisting in simple procedures, under supervision • Develop familiarity with surgical instruments and suture materials • Position and drape patients for general surgical procedures • Demonstrate the principles of gentle tissue handling

The junior resident will be able to: • Perform the above technical skills • Perform some common general surgical procedures, under supervision

The senior/chief resident will be able to: • Perform the above technical skills • Competently and independently perform most general surgical procedures • Lead a team in the safe ,effective and efficient operative management of patients • Deal with operative circumstances that may be unusual or unexpected • Supervise and teach more junior residents in performing operative procedures

Having completed the rotation in General Surgery, the resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Operative Procedures PGY-1 Junior Senior/Chief General Diagnostic and Therapeutic Procedures Arterial puncture S S S Venipuncture/venous cutdown S S S Central venous catheter insertion S S S Insertion/removal of venous access reservoir (Portacath) S S S Endotracheal intubation S S S Insertion/removal of peritoneal dialysis catheter S S S Injection of varicose veins S S S Urinary catheter insertion S S S Nasogastric tube insertion S S S Tracheostomy A S S Cricothyrotomy A S S Needle/tube thoracostomy S S S Pericardiocentesis for trauma A S S Pericardiotomy for trauma A S S Paracentesis/diagnostic peritoneal lavage S S S Integumentary System Incision/drainage of subcutaneous abscess S S S Foreign body removal S S S

Page 2.1.8 Learning Objectives (Mandatory) – General Surgery

Operative Procedures PGY-1 Junior Senior/Chief Excision of benign skin lesions S S S Wide excision of melanoma A S S Excision of subcutaneous lesions S S S Excision of pilonidal sinus disease S S S Excision of hidradenitis suppurativa A S S Suture of laceration S S S Creation of skin flaps A S S Split thickness skin grafts A S S Full thickness skin grafts A S S Breast Aspiration of breast mass/lesion S S S Core biopsy (True-cut) of breast mass S S S Incision/drainage of breast abscess S S S Excision of benign breast neoplasm S S S Partial mastectomy/lumpectomy A S S Total (simple) mastectomy A S S Modified radical mastectomy A A S Axillary dissection A A S Sentinel lymph node biopsy A A S Excision of mammary ducts (Adair) A S S Subcutaneous mastectomy A A S Head and Neck Excision of thyroglossal duct cyst (Sistrunk) A A S Excision of cystic hygroma A A S Excision of branchial cleft cyst/sinus A A S Excisional biopsy of cervical lymph node A S S Radical/modified radical neck dissection A A A/S Excision of parotid gland A A S Excision of submandibular gland A A S Thyroid lobectomy A A S Total thyroidectomy A A S V-excision of lip cancer A S S Vermilionectomy A S S Biopsy of premalignant/malignant oral cavity lesion A S S Hematologic/Lymphatic Biopsy of enlarged lymph nodes (cervical; axillary; inguinal; A S S scalene) Staging laparotomy for Hodgkin’s disease A A S Ileoinguinal lymph node dissection A A S Open splenectomy A A/S S Laparoscopic splenectomy A A A/S Endoscopic Procedures Esophagogastroduodenoscopy NA S S Colonoscopy NA S S Flexible sigmoidoscopy NA S S Rigid sigmoidoscopy S S S Endoscopic biopsy techniques NA S S Endoscopic injection therapy NA S S Endoscopic variceal banding NA S S Hemorrhoid banding S S S

Page 2.1.9 Learning Objectives (Mandatory) – General Surgery

Operative Procedures PGY-1 Junior Senior/Chief Endoscopic polypectomy NA S S Endoscopic thermal techniques NA S S Endoscopic detorsion of sigmoid volvulus NA S S Percutaneous endoscopic gastrostomy A A S Endoscopic dilation techniques NA S S Diagnostic laparoscopy A S S Choledochoscopy A A/S S Esophageal Procedures Laparoscopic esophagomyotomy (Heller myotomy) A A A/S Open transabdominal hiatus hernia repair/fundoplication A A A/S Laparoscopic transabdominal hiatus hernia A A A/S repair/fundoplication Repair of perforated esophagus A A S Repair of Mallory-Weiss tear A A S Esophagogastrectomy A A A/S Gastroduodenal Procedures Open wedge excision of gastric GIST/other lesions A A S Laparoscopic excision of gastric GIST/other lesions A A A/S Open partial gastric resection with Billroth I/Billroth II/Roux- A A/S S en-y reconstruction Laparoscopic partial gastric resection with Billroth I/Billroth A A A/S II/Roux-en-y reconstruction Open total gastrectomy A A S Open gastroenterotomy A S S Laparoscopic gastroenterotomy A A A/S Open surgical gastrostomy techniques (Stamm/Janeway) A A/S S Laparoscopic surgical gastrostomy techniques A A A/S Open pyloroplasty A A/S S Laparoscopic pyloroplasty A A A/S Open pyloromyotomy A A/S S Laparoscopic pyloromyotomy A A/S A/S Open gastrotomy and oversewing of bleeding gastric ulcer A A/S S Oversewing of bleeding duodenal ulcer A A/S S Vagotomy techniques A A A/S Open omental patch of perforated peptic ulcer A S S Laparoscopic omental patch of perforated peptic ulcer A A S Laparoscopic gastric bypass with Roux-en-y A A A gastrojejunostomy for morbid obesity Small Intestinal Procedures Open enterostomy (end/loop/feeding) A S S Laparoscopic enterostomy A A S Closure of enterostomy A A S Laparotomy and enterolysis for intestinal obstruction A A/S S Open small intestinal resection/anastomosis A S S Laparoscopic small intestinal resection/anastomosis A A A/S Open resection of Meckel’s diverticulum A S S Laparoscopic resection of Meckel’s diverticulum A A S Open enteroanastomosis A S S Laparoscopic enteroanastomosis A A A/S Stricturoplasty for Crohn’s disease A A/S S

Page 2.1.10 Learning Objectives (Mandatory) – General Surgery

Operative Procedures PGY-1 Junior Senior/Chief Colon and Rectal Procedures Open appendectomy A/S S S Laparoscopic appendectomy A S S Open colostomy (end/loop) A A/S S Laparoscopic colostomy A A A/S Colostomy closure A A/S S Open colonic resection/anastomosis (segmental/subtotal) A A/S S Sigmoid resection with Hartmann for perforated A A/S S diverticulitis Laparoscopic colonic resection (segmental/subtotal) A A/S S Open anterior resection with total mesorectal excision A A/S S (TME) Laparoscopic anterior resection with total mesorctal A A S excision (TME) Open abdominoperineal resection with total mesorectal A A/S S excision (including perineal portion of the procedure) Laparoscopic-assisted abdominoperineal resection with A A A/S total mesorectal excision (including perineal portion of the procedure) Total proctocolectomy with Brooke ileostomy for colitis A A S Pelvic pouch procedure with stapled j-pouch for ulcerative A A A/S colitis Pelvic pouch procedure with total colectomy/rectal A A A/S mucosectomy and stapled j-pouch/handsewn ileoanal anastomosis for FAP/dysplasia Open takedown of Hartmann A A/S S Laparoscopic takedown of Hartmann A A A/S Transanal excision of rectal polyp A S S Laparoscopic repair of rectal prolapse A A A/S Perineal rectosigmoidectomy for rectal prolapse A A/S S Anorectal Procedures Excision of thrombosed hemorrhoid S S S Hemorrhoidectomy A A/S S Hemorrhoid banding S S S Hemorrhoid injection S S S Stapled hemorrhoidopexy A A A/S Lateral internal sphincterotomy for anal fissure A A/S S Excision of anal fissure A A/S S Incision/drainage of perianal abscess S S S Incision/drainage of ischiorectal abscess S S S Anal fistulotomy techniques, including: A A/S S • Probing of fistula tract • Seton placement • Mucosal advancement flap • Fistula plug placement Anoplasty with v-y mucosal advancement flap A A/S S Anal dilatation S S S Anal sphincter repair A A A/S Excision/fulguration of condylomata acuminata A A/S S Excision and mapping for AIN/Bowen’s disease A A/S S Repair of rectovaginal fistula with mucosal advancement A A S flap

Page 2.1.11 Learning Objectives (Mandatory) – General Surgery

Operative Procedures PGY-1 Junior Senior/Chief Incision/drainage of pilonidal abscess S S S Excision of pilonidal sinus disease A S S Liver Procedures Open liver biopsy A S S Laparoscopic liver biopsy A A/S S Wedge excision of liver lesion A A/S S Left lateral segmentectomy A A/S S Left hepatic lobectomy A A A/S Right hepatic lobectomy A A A/S Left trisegmentectomy A A A/S Right hepatic lobectomy A A A/S Right trisegmentectomy A A A/S Open radiofrequency ablation of liver lesion A A A/S Open decompression/management of liver abscess/cyst A A/S S Laparoscopic decompression/management of liver A A A/S abscess/cyst Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and cholangiography A S S Open cholecystostomy A S S Laparoscopic cholecystostomy A S S Open common bile duct exploration A A S Laparoscopic common bile duct exploration A A A/S Biliary-intestinal anastomosis A A/S S Operative management of choledochal cyst or neoplasm A A/S S Pancreatic Procedures Drainage of pancreatic abscess A S A/S Pancreatic necrosectomy A A/S S Open drainage of pancreatic pseudocyst by anastomosis to A A/S S stomach or intestine Laparoscopic drainage of pancreatic pseudocyst by A A A/S anatomosis to stomach or intestine Puestow procedure A A A/S Local excision of pancreatic lesion A A/S S Distal pancreatectomy A A/S A/S Pancreaticoduodenectomy (Whipple procedure) A A A/S Hernia and Abdominal Wall Procedures Elective open repair of inguinal hernia using tension-free A S S mesh technique Elective laparoscopic repair of inguinal hernia A A/S S Emergency repair of incarcerated/strangulated inguinal A A/S S hernia using Cooper’s ligament (McVay) technique Elective open repair of femoral hernia using tension-free A S S mesh technique Elective laparoscopic repair of femoral hernia A A/S S Emergency repair of incarcerated/strangulated femoral A A/S S hernia using Cooper’s ligament (McVay) technique Open repair of ventral (incisional) hernia A S S Laparoscopic repair of ventral (incisional) hernia A A/S A/S Repair of parastomal hernia A A/S S Repair of lumbar hernia A A/S S

Page 2.1.12 Learning Objectives (Mandatory) – General Surgery

Operative Procedures PGY-1 Junior Senior/Chief Open repair of Spigelian hernia A A/S S Laparoscopic repair of Spigelian hernia A A S Emergency repair of obturator hernia A A/S S Emergency repair of fascial dehiscence/evisceration A S S Repair of hydrocele A S S Incision/drainage of abdominal wall abscess S S S Adrenal Procedures Laparoscopic adrenalectomy A A A/S Procedures for Trauma Diagnostic peritoneal lavage (DPL) S S S Focused Assessment with Sonography for Trauma (FAST) A A A/S examination Cricothyroidotomy A A/S S Pericardiocentesis for tamponade A A/S S Emergency room thoracotomy for penetrating cardiac injury A A S and cardiac arrest Needle decompression for tension pneumothorax S S S Chest tube insertion for chest trauma S S S Emergency neck exploration for penetrating trauma A A A/S Laparotomy for trauma (including damage control A A/S S techniques) Repair of liver injuries A A S Repair of diaphragmatic injury A A S Repair of gastrointestinal tract injuries A A/S S Pyloric exclusion for duodenal/pancreatic injury A A S Pancreatic resection for trauma A A A/S Repair of bile duct injuries using t-tube A A S Biliary-intestinal anastomosis for bile duct injuries A A S Splenectomy for trauma A A/S S Splenic repair for trauma A A/S S

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal patient care • Arrange appropriate follow-up care services for a patient and his/her family

Educational Strategies The General Surgery resident will achieve the objectives by means of the following: • Self-directed learning • Role modeling in the learning environment • Exposure/experience on the teaching units and in the operating room • Problem-based learning at rounds and at academic sessions • Workshops and skills labs covering relevant topics

Page 2.1.13 Learning Objectives (Mandatory) – General Surgery

Evaluation Strategies The General Surgery resident will be assessed with respect to the objectives by means of the following: • In-training evaluation of observed behaviours/performance (360 degree assessment) • Objective written examinations (CAGS examination) • Structured oral examinations

¾ Communicator Communication is an essential component of virtually all aspects of general surgical practice and forms the cornerstone of the physician-patient relationship. Good communication skills are necessary for eliciting information from patients and their families about their medical conditions, their beliefs, expectations and associated concerns and for providing appropriate explanations and guidance. Communication with colleagues and other health professionals is also integral to the role of the General Surgeon. At the completion of training, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Gather information about a disease, but also about a patient’s beliefs, concerns, expectations and illness experience • Seek out and synthesize relevant information from other sources, such as a patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to a patient and family, colleagues and other professionals in a humane manner and in a way that it is understandable, encourages discussion and participation in decision-making

Develop a common understanding on issues, problems and plans with patients, families and other professionals • Respect diversity and difference, including the impact of gender, religion and cultural beliefs on decision-making • Engage patients, families and relevant health professionals in shared decision-making • Effectively address issues such as obtaining informed consent, delivering bad news and dealing with anger, confusion and misunderstanding

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records (e.g. written or electronic) of clinical encounters and operative procedures • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the General Surgery residency • Effectively present verbal reports of clinical encounters and medical information

Page 2.1.14 Learning Objectives (Mandatory) – General Surgery

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • A learning environment that encourages respect, empathy and good communication • Role modeling • Communications skills discussions at academic sessions • Communications skills workshops

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • In-training evaluation of observed behaviours (360 degree assessment)

¾ Collaborator General Surgeons work in partnership with others who are appropriately involved in the care of individuals or specific groups of patients. It is essential that General Surgeons collaborate with patients, families and an interprofessional team of health professionals for the provision of optimal care, education and scholarship. At the completion of training, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals • Work with others to assess, plan, provide and integrate care for patients • Work with others to assess, plan, provide and review tasks such as research and educational assignments • Participate effectively in interprofessional team meetings (e.g. surgical service rounds; multidisciplinary teaching rounds) • Respect team ethics, including confidentiality, resource allocation and professionalism • Demonstrate leadership in a healthcare team (e.g. surgical teaching unit senior resident; chief resident in General Surgery; Trauma (Gold Surgery) senior resident team leader)

Effectively work with other health professionals to prevent, negotiate, and resolve interprofessional conflict • Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team • Work with other professionals to prevent conflicts • Employ collaborative negotiation to resolve conflicts • Respect differences, misunderstandings and limitations in other professionals • Recognize one’s own differences, misunderstandings and limitations that may contribute to interprofessional tension

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • Role modeling within the learning environment (e.g. nutrition support team; trauma team; the operating room team) • Interdisciplinary sessions (e.g. service rounds)

Page 2.1.15 Learning Objectives (Mandatory) – General Surgery

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • In-training evaluation of observed behaviours (360 degree assessment)

¾ Manager General Surgeons function as managers in a variety of settings within the health care system. They must be able to manage their own clinical practices and their personal lives. They may play a supervisory role within the health care environment. Furthermore, part of their role as managers involves the establishment of priorities and the participation in decision-making that affects the allocation of finite health care resources. At the completion of training, the General Surgery resident will be able to:

Participate in activities that contribute to the effectiveness of the health care system • Work collaboratively with others (e.g. surgical units; operating room; emergency room) • Participate in systemic quality process evaluation and improvement (e.g. new technologies; patient “time-out” in the operating room and other patient safety initiatives)

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Demonstrate an understanding of practice management, including finances and human resources • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Recognize the importance of just allocation of healthcare resources

Serve in leadership roles, as appropriate • Participate effectively in meetings (e.g. teaching rounds; surgical service rounds) • Lead a team effectively and efficiently (e.g. Senior resident trauma team leader) • Plan relevant elements of health care delivery (e.g. coordinating on-call schedules)

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • Role modeling • Practice management workshops (e.g. MD Management workshop)

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • In-training evaluation of observed behaviours

Page 2.1.16 Learning Objectives (Mandatory) – General Surgery

¾ Health Advocate General Surgeons recognize their duty and ability to improve the overall health of their patients and the society they serve. At the completion of training, the General Surgery resident will be able to:

Respond to individual health needs and issues as part of patient care • Identify the health needs of an individual patient (e.g. patient work-up, management and discharge planning and instructions) • Identify opportunities for advocacy, health promotion and disease prevention with individuals to whom he/she provides care (e.g. Home Care Services referral; Social Services referral; arrangements for colorectal and other cancer screening and surveillance examinations)

Promote the health of individual patients, communities and populations • Identify points of influence in the healthcare system and its structure (e.g. regional health authority) • Describe the role of the medical profession (e.g. Canadian Association of General Surgeons) in advocating collectively for health and patient safety (e.g. helmet and seatbelt legislation; snowmobile safety)

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • Role modeling • Educational workshops

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • In-training evaluation of observed behaviours (360 degree evaluation) • Objective written examinations (CAGS exam)

¾ Scholar General Surgeons engage in a lifelong pursuit of mastering their domain of expertise. As learners, they recognize the need to be continually learning this for others. Through their scholarly activities, they contribute to the creation, dissemination, application and translation of knowledge. As teachers, they facilitate the education of students, patients, colleagues and others. At the completion of training, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Understand the principles of maintenance of competence • Understand the principles and strategies for implementing a personal knowledge management system • Conduct a personal practice audit • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into practice • Evaluate the outcomes of any changes in practice

Page 2.1.17 Learning Objectives (Mandatory) – General Surgery

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Understand the principles of critical appraisal • Critically appraise retrieved evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of patients, families, students, colleagues and others, as appropriate • Understand the principles of learning relevant to medical education • Collaboratively identify the learning needs and desired learning outcomes of others • Select effective teaching strategies and content to facilitate learning • Provide effective feedback

Contribute to the development, dissemination and translation of new knowledge and practice • Understand the principles of research and scholarly inquiry • Understand the principles of research ethics • Pose a scholarly question • Conduct a systematic search for evidence • Select and apply appropriate methods to address the question • Appropriately disseminate the findings of a study

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • A learning environment that encourages self-directed and lifelong learning and evidence-based practice of General Surgery • Academic sessions/seminars/lectures • General Surgery Journal Club (CAGS Evidence-Based Surgery Reviews) • Attendance/presentation at local, national and international surgical/medical meetings (e.g. Canadian Surgery Forum) • Involvement in research projects/Master of Science in Surgery • TIPS workshop

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • Direct observation of the resident’s teaching skills in seminars, lectures and case presentations • Written evaluations from students • Assessment of resident research projects and publications

Page 2.1.18 Learning Objectives (Mandatory) – General Surgery

¾ Professional General Surgeons have a unique role in society as professionals. They have mastered a complex body of knowledge and skills. They are guided by a code of ethics and a commitment to clinical competence, the embracing of appropriate attitudes and behaviours, integrity, altruism, personal well-being and to the promotion of the public good within their domain. At the completion of training, the General Surgery resident will be able to:

Demonstrate a commitment to his/her patients, profession and society through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Demonstrate a commitment to delivering the highest quality care and maintenance of competence • Recognize and appropriately respond to ethical issues encountered in practice • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality as defined by professional practice standards and the law • Maintain appropriate relations with patients

Demonstrate a commitment to his/her patients, profession and society through participation in profession-led regulation • Appreciate the professional, legal and ethical codes of practice • Demonstrate accountability to professional regulatory bodies • Recognize and respond to others’ unprofessional behaviours in practice • Participate in peer review (e.g. morbidity and mortality reviews; review of patients at surgical service rounds; death reviews)

Demonstrate a commitment to his/her professional and personal health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight • Recognize other professionals in need and respond appropriately

Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • A learning environment where the professional/ethical principles are observed • Role modeling of professional attitudes and behaviours • Discussion of ethical issues at rounds and seminars • Bioethics Education Project sponsored by the Royal College of Physicians and Surgeons of Canada (RCPSC) • Medico-legal topics discussed at rounds and academic sessions (e.g. Canadian Medical Protective Association seminars)

Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • In-training evaluation of observed behaviours (360 degree evaluation)

Page 2.1.19 Learning Objectives (Mandatory) – General Surgery – A-Service

2.2: GENERAL SURGERY – A-SERVICE

PREAMBLE The rotation on A-Service General Surgery provides the General Surgery residents with the opportunity for concentrated exposure to a broad spectrum of general surgical conditions. Several focus areas include breast, gastrointestinal/colorectal and minimal access surgery. The A-Service experience offers exposure to the clinical problems commonly seen by the practicing general surgeon on an elective and on an acute care basis.

GENERAL OBJECTIVES Upon completion of the A-Service General Surgery rotation, the General Surgery resident is expected to acquire the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies pertinent to the A-Service General Surgery rotation, including gender-related and ethnic perspectives. The resident is advised to review the Learning Objectives for General Surgery Residents on General Surgery Rotations in conjunction with these rotation-specific objectives.

SPECIFIC OBJECTIVES At the completion of the A-Service General Surgery rotation, the General Surgery resident will have acquired the following competencies and will function as:

¾ Medical Expert At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the A- Service General Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the A-Service General Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the following areas: o Breast and axilla o Upper gastrointestinal system o Lower gastrointestinal system o Biliary tract o Retroperitoneum o Spleen/pancreas o Inguinal/femoral • Physiology, including: o Gastrointestinal/function/motility o Biliary/bile composition and function o Spleen/hematopoietic system

Page 2.2.1 Learning Objectives (Mandatory) – General Surgery – A-Service

• Medical problems in the surgical patient, including: o Preoperative assessment o Preparation for specific operative interventions (e.g. bowel preparation for colorectal surgery) o Antimicrobial prophylaxis o Anticoagulation/thromboembolic prophylaxis o Corticosteroid management o Diabetes management • Conduct of a surgical procedure, including: o General principles o Specific operative interventions • Postoperative care, including: o Prevention and treatment of postoperative infections o Management of cardiac/hypertensive complications o Management of thromboembolic complications o Management of pulmonary complications o Management of endocrine/metabolic problems (e.g. diabetes) o Management of fluid and electrolyte/renal problems • Wound management and healing/biomaterials for hernia repair • Sepsis and surgical infections • Hemostasis and use of blood products • Fluid management and acid-base problems • Metabolic and nutritional care • Cancer, including: o Principles of neoplasia o Diagnosis and staging o Therapeutic options o Principles of chemotherapy o Principles of radiation oncology • Imaging for the general surgeon, including: o Plain x-rays o Mammography/stereotactic breast biopsy o Contrast studies and interventional radiology o CT/colonography o Ultrasound/endoscopic ultrasound o MRI/MRCP o Nuclear medicine studies (scintigraphy) o PET • Diagnostic/therapeutic GI endoscopy, including: o Upper GI endoscopy o Colonoscopy/sigmoidoscopy o ERCP • Laboratory medicine for the general surgeon, including: o Hematology o Biochemistry o Microbiology o GI laboratory studies, including: ƒ Esophageal manometry/pH ƒ Anorectal manometry

Page 2.2.2 Learning Objectives (Mandatory) – General Surgery – A-Service

¬ Acute Surgical Problems • Principles of early assessment and investigation in the acute abdomen, including: o Conditions associated with abdominal pain, including: ƒ Acute appendicitis ƒ Cholecystitis/biliary colic/choledocholithiasis/cholangitis ƒ Pancreatitis ƒ Peptic ulcer disease (with or without perforation) ƒ Gastroesophageal reflux ƒ Gastritis/duodenitis ƒ Diverticulitis ƒ Inflammatory bowel disease ƒ Enterocolitis ƒ Small intestinal obstruction ƒ Colonic obstruction ƒ Splenomegaly ƒ Mesenteric ischemia ƒ Leaking/ruptured abdominal aortic aneurysm ƒ Gynecologic conditions, including: à Ectopic pregnancy à Tubo-ovarian abscess à Salpingitis à Endometritis ƒ Genito-urinary conditions, including: à Urosepsis à Pyelonephritis à Ureterolithiasis à Testicular torsion ƒ Common non-surgical conditions that can present with abdominal pain, including: à Myocardial infarction à Pneumonia à Pleuritis à Hepatitis à Gastroenteritis à Mesenteric adenitis à Sickle cell crisis à Diabetic ketoacidosis à Herpes zoster à Nerve root compression à Myofascial syndrome ƒ Conditions causing abdominal pain in the immune-compromised patient, including: à Neutropenic enterocolitis à CMV enterocolitis o Investigations, including: ƒ Blood tests ƒ Diagnostic imaging ƒ Endoscopy/laparoscopy o Early management of patients with acute abdominal pain, including: ƒ Operative versus nonoperative approach

Page 2.2.3 Learning Objectives (Mandatory) – General Surgery – A-Service

• Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common surgical emergencies, including: o Perforations of the upper gastrointestinal tract, including: ƒ Esophageal perforation ƒ Perforated peptic ulcer ƒ Perforated gastric lesions o Gastrointestinal hemorrhage, including: ƒ Acute non-variceal upper gastrointestinal bleeding ƒ Acute variceal upper gastrointestinal bleeding ƒ Hematobilia ƒ Aorto-enteric fistula ƒ Acute lower gastrointestinal bleeding o Pancreaticobiliary emergencies, including: ƒ Biliary colic/acute cholecystitis/acalculous cholecystitis ƒ The acutely jaundiced patient ƒ Choledocholithiasis/cholangitis ƒ Acute pancreatitis/necrotizing pancreatitis o Hepatic emergencies, including: ƒ Acute abscess ƒ Infected cyst o Small intestinal emergencies, including: ƒ Obstruction ƒ Mesenteric ischemia ƒ Inflammatory conditions, including: à Crohn’s disease à Radiation enteritis ƒ Meckel’s diverticulum ƒ Bleeding o Acute appendicitis/perforation/phlegmon o Colorectal emergencies, including: ƒ Colonic obstruction ƒ Intestinal pseudo-obstruction ƒ Acute colorectal bleeding ƒ Colonic perforation ƒ Volvulus, including: à Cecal volvulus à Sigmoid volvulus ƒ Acute diverticulitis, including the following complications: à Perforation à Abscess à Obstruction à Bleeding ƒ Emergencies related to colorectal malignancy ƒ Emergencies related to inflammatory bowel disease, including: à Ulcerative colitis à Crohn’s disease ƒ Emergencies related to pseudomembranous colitis ƒ Ischemic colitis ƒ Radiation proctocolitis

Page 2.2.4 Learning Objectives (Mandatory) – General Surgery – A-Service

o Anorectal emergencies, including: ƒ Ischiorectal/perianal abscess ƒ Acute anal fissure ƒ Acute hemorrhoid emergencies, including: à Thrombosis à Prolapse/gangrene à Bleeding ƒ Pilondal abscess ƒ Foreign body ƒ Fulminating sepsis/fasciitis/myonecrosis o Acute conditions related to hernias of the abdominal wall, groin (inguinal/femoral) and obturator foramen, including: ƒ Incarceration ƒ Strangulation ƒ Obstruction o Soft tissue infection, including: ƒ Cellulitis ƒ Abscess ƒ Fulminating sepsis, including: à Fasciitis à Myonecrosis à Fournier’s gangrene ¬ Breast Diseases • Definition of neoplasm, abscess and hyperplasia • Distinguishing benign from malignant neoplasms • Classification of breast neoplasm (benign and malignant) • Physical characteristics of breast cancer • Risk factors for breast cancer • Age-related variations in presentation profile for breast cancer and the differential diagnosis • Options available for breast screening • Initial assessment of a woman with: o Breast mass o Nipple discharge o Recent nipple retraction o Breast pain o Diffuse nodular breast tissue o Isolated axillary lymphadenopathy • The clinical presentation, assessment and care of a woman with: o Ductal carcinoma in-situ o Atypical hyperplasia • The clinical presentation, assessment and management of a male with gynecomastia • The clinical presentation, assessment and management of the following: o Acute breast cellulites/abscess o Chronic cellulites with sinus formation o Macrocystic disease o Fibroadenoma o Duct ectasia

Page 2.2.5 Learning Objectives (Mandatory) – General Surgery – A-Service

• The indications for and the complications associated with the following procedures: o Fine needle aspiration biopsy o Core needle biopsy o Excision biopsy o Needle localization biopsy o Incision/drainage o Segmental mastectomy (lumpectomy) o Total mastectomy o Subcutaneous mastectomy o Axillary lymph node biopsy o Sentinel lymph node biopsy o Axillary lymph node dissection • Detailed description of each of the above procedures with reference to the following: o Selection of the incision o Sequence of steps in the operation o Normal anatomic relations o Possible extension of the operation o Specific technical problems o Specimen handling o Expected outcomes/consequences as distinct from complications • The role and the technical aspects of radiotherapy for breast cancer • Breast reconstruction options available for women • Advantages and disadvantages of immediate versus delayed breast reconstruction ¬ Non-Emergency Gastrointestinal/Colorectal Diseases • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of the following: o Gastroesophageal reflux disease/hiatus hernia/Barrett’s o Achalasia o Peptic ulcer disease/H pylori o Gastric neoplasia, including: ƒ GIST ƒ Adenocarcinoma ƒ Lymphoma/MALT o Inflammatory bowel disease, including: ƒ Ulcerative colitis/pelvic pouch procedure ƒ Crohn’s, including: à Gastroduodenal à Small intestine à Large intestine/anorectal o Gastrointestinal fistulas o Small intestinal neoplasia, including: ƒ Polyps ƒ GIST ƒ Adenocarcinoma ƒ Lymphoma ƒ Carcinoid tumour/carcinoid syndrome o Polyps of the colon and rectum, including: ƒ Classification ƒ Polyp syndromes/molecular genetic aspects ƒ Screening/surveillance ƒ Surgical options

Page 2.2.6 Learning Objectives (Mandatory) – General Surgery – A-Service

o Colorectal cancer, including: ƒ Molecular genetic aspects/HNPCC ƒ Staging ƒ Multidisciplinary management ƒ Screening/surveillance o Intestinal stomas, including: ƒ Ileostomy ƒ Colostomy o Rectal prolapse o Anorectal disorders, including: ƒ Hemorrhoids ƒ Anal fissure/ulcer ƒ Anal fistula, including: à Classification à Salmon-Goodsall rule à Management options/approach ƒ Rectovaginal fistula ƒ Anal neoplasms ¬ Non-Emergency Biliary Tract Diseases • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common non-emergent biliary tract disorders, including: o Approach to the jaundiced patient o Calculous biliary disease, including: ƒ Gallstone pathogenesis ƒ Laparoscopic/open cholecystectomy ƒ Choledocholithiasis ƒ Laparoscopic/open common bile duct exploration o Polypoid lesions of the gallbladder o Bile duct injury, including: ƒ Classification ƒ Diagnosis/recognition ƒ Initial approach to management o Gallbladder cancer ¬ Non-Emergency Splenic Diseases • Operative indications for splenectomy, including: o Hypersplenism o Autoimmune/erythrocyte disorders o Cysts/tumours o Diagnostic o Iatrogenic o Incidental • Laparoscopic/open splenectomy, including: o Indications o Technical considerations o Complications o Expected outcomes ¬ Minimal Access Surgery • Basic principles of minimal access surgery • Indications, technical considerations, complications and expected outcomes for the following specific minimal access operative procedures performed on the A-Service General Surgery rotation: o Biliary tract procedures, including: ƒ Cholecystectomy ƒ Common bile duct exploration

Page 2.2.7 Learning Objectives (Mandatory) – General Surgery – A-Service

o Foregut procedures, including: ƒ Antireflux operations ƒ Heller myotomy for achalasia ƒ Gastric resection ƒ Gastroenterostomy o Colorectal procedures, including: ƒ Appendectomy ƒ Ileocolonic resection ƒ Colectomy ƒ Anterior resection ƒ Abdominoperineal resection o Splenectomy o Adrenalectomy o Hernia repair, including: ƒ Groin hernia ƒ Ventral hernia

With respect to the above outline of cognitive objectives: • The PGY-1 resident and the junior resident will be able to outline the initial management of the listed conditions • The senior/chief resident will be able to describe the listed conditions beyond initial management, including operative procedures, perioperative considerations, complications, expected outcomes and follow-up

Perform a complete and appropriate assessment of the general surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the general surgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the general surgical patient, including appropriate and expeditious patient disposition in the acute care setting • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the A-Service General Surgery rotation • Ensure appropriate informed consent is obtained for therapies

The PGY-1 resident and the junior resident will be able to: • Perform many of the above clinical skills • Initiate well thought-out and appropriate management strategies; will require corroboration or modification by a more senior individual

The senior/chief resident will be able to: • Perform the above clinical skills • Formulate management strategies completely • Coordinate team members and consultants in the development, documentation and execution of clear and integrated management plans

Page 2.2.8 Learning Objectives (Mandatory) – General Surgery – A-Service

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the A-Service General Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the A-Service General Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the A-Service General Surgery rotation

Having completed the A-Service General Surgery rotation, the General Surgery resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Operative Procedures PGY-1 Junior Senior/Chief General Diagnostic and Therapeutic Procedures Arterial puncture S S S Venipuncture S S S Venous cutdown S S S Central venous catheter insertion S S S Insertion/removal of venous access reservoir (Portacath) S S S Removal of peritoneal dialysis catheter S S S Urinary catheter insertion S S S Nasogastric tube insertion S S S Integumentary System Incision/drainage of subcutaneous abscess S S S Excision of subcutaneous lesions S S S Excision of pilonidal sinus disease S S S Breast Fine needle aspiration biopsy S S S Breast cyst aspiration S S S True-cut core biopsy S S S Excision biopsy for benign lesion S S S Excision biopsy for suspected cancer under local S S S anesthesia Excision biopsy for suspected cancer after needle A S S localization Excision biopsy for suspected cancer for a central lesion A S S Excision biopsy for suspected cancer in the manner of a A S S lumpectomy Segmental mastectomy A S S Sentinel lymph node biopsy A A/S S Axillary dissection (Levels I and II) A A/S S Total mastectomy +/- axillary dissection A A/S S Subcutaneous mastectomy A A S

Page 2.2.9 Learning Objectives (Mandatory) – General Surgery – A-Service

Operative Procedures PGY-1 Junior Senior/Chief Hematologic/Lymphatic Biopsy of enlarged lymph nodes (cervical; axillary; inguinal; A S S scalene) Open splenectomy A A/S S Laparoscopic splenectomy A A A/S Endoscopic Procedures Flexible sigmoidoscopy NA S S Rigid sigmoidoscopy NA S S Percutaneous endoscopic gastrostomy (PEG) NA S S Diagnostic laparoscopy A S S Esophageal Procedures Laparoscopic esophagomyotomy (Heller myotomy) A A A/S Open transabdominal hiatus hernia repair/fundoplication A A A/S Laparoscopic transabdominal hiatus hernia A A A/S repair/fundoplication Esophagogastrectomy A A A/S Gastroduodenal Procedures Open wedge excision of gastric GIST/other lesions A A S Laparoscopic excision of gastric GIST/other lesions A A A/S Open partial gastric resection with Billroth I/Billroth II/Roux- A A S en-y reconstruction Laparoscopic partial gastric resection with Billroth I/Billroth A A A/S II/Roux-en-y reconstruction Open total gastrectomy A A S Open gastroenterotomy A S S Laparoscopic gastroenterotomy A A A/S Open surgical gastrostomy techniques A A/S S Laparoscopic surgical gastrostomy techniques A A A/S Open pyloroplasty A A/S S Laparoscopic pyloroplasty A A A/S Open gastrotomy and oversewing of bleeding gastric A A S ulcer/erosion Duodenotomy/pylorotomy and oversewing of bleeding A A/S S duodenal ulcer Vagotomy techniques for peptic ulcer A A A/S Open omental patch of perforated peptic ulcer A S S Laparoscopic omental patch of perforated peptic ulcer A A S Laparoscopic gastric bypass/Roux-en-y gastrojejunostomy A A A for morbid obesity Small Intestinal Procedures Open enterostomy (feeding/loop) A S S Laparoscopic enterostomy A A S Closure of enterostomy A A S Laparotomy and enterolysis for intestinal obstruction A A/S S Open small intestinal resection/anastomosis A A/S S Laparoscopic small intestinal resection/anastomosis A A A/S Open resection of Meckel’s diverticulum A A/S S Laparoscopic resection of Meckel’s diverticulum A A S Open enteroanatomosis A A/S S Laparoscopic enteroanastomosis A A A/S Stricturoplasty for Crohn’s disease A A/S S

Page 2.2.10 Learning Objectives (Mandatory) – General Surgery – A-Service

Operative Procedures PGY-1 Junior Senior/Chief Colon and Rectal Procedures Open appendectomy A/S S S Laparoscopic appendectomy A S S Open colostomy (end/loop) A A/S S Laparoscopic colostomy A A A/S Colostomy closure A A/S S Open colonic resection/anastomosis (segmental/subtotal) A A/S S Open sigmoid resection with Hartmann for perforated A A/S S diverticulitis Laparoscopic colonic resection (segmental/subtotal) A A/S S Open anterior resection with total mesorectal excision A A/S S (TME) Laparoscopic anterior resection with total mesorectal A A A/S excision (TME) Abdominoperineal resection with total mesorectal excision A A/S S (including perineal portion of the procedure) Laparoscopic-assisted abdominoperineal resection with A A A/S total mesorectal excision (including perineal portion of the procedure) Total proctocolectomy with Brooke ileostomy for colitis A A S Pelvic pouch procedure with stapled j-pouch for ulcerative A A A/S colitis Pelvic pouch procedure with total colectomy/rectal A A A/S mucosectomy and stapled j-pouch/handsewn ileoanal anastomosis for FAP/dysplasia Open takedown of Hartmann A A/S S Laparoscopic takedown of Hartmann A A A/S Transanal excision of rectal polyp A S S Perineal rectosigmoidectomy for rectal prolapse A A/S S Anorectal Procedures Excision of thrombosed hemorrhoid S S S Hemorrhoidectomy A A/S S Lateral internal sphincterotomy for anal fissure A A/S S Excision of anal fissure A A/S S Incision/drainage of perianal abscess S S S Incision/drainage of ischiorectal abscess S S S Anal dilatation S S S Anal fistulotomy techniques, including: A A/S S • Probing of fistula tract • Seton placement • Mucosal advancement flap • Fistula plug placement Anoplasty with v-y mucosal advancement flap A A/S S Incision/drainage of pilonidal abscess S S S Excision of pilonidal sinus disease A S S Excision and mapping of AIN/Bowen’s disease A A/S S Repair of rectovaginal fistula with mucosal advancement A A S flap Liver Procedures Open liver biopsy A S S Laparoscopic liver biopsy A A/S S Wedge excision of liver lesion A A/S S

Page 2.2.11 Learning Objectives (Mandatory) – General Surgery – A-Service

Operative Procedures PGY-1 Junior Senior/Chief Open decompression/management of liver abscess/cyst A A S Laparoscopic decompression/management of liver A A A/S abscess/cyst Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and cholangiography A S S Open cholecystostomy A S S Laparoscopic cholecystostomy A S S Open common bile duct exploration A A S Laparoscopic common bile duct exploration A A A/S Biliary-intestinal anastomosis A A S Pancreatic Procedures Drainage of pancreatic abscess A A/S S Pancreatic necrosectomy A A S Open drainage of pancreatic pseudocyst by anastomosis to A A/S S stomach or intestine Laparoscopic drainage of pancreatic pseudocyst by A A A/S anastomosis to stomach or intestine Distal pancreatectomy A A/S A/S Hernia and Abdominal Wall Procedures Elective open repair of inguinal hernia using tension-free A S S mesh technique Elective laparoscopic repair of inguinal hernia A A/S S Emergency repair of incarcerated/strangulated inguinal A A/S S hernia using Cooper’s ligament (McVay) technique Elective open repair of femoral hernia using tension-free A S S mesh technique Elective laparoscopic repair of femoral hernia A A/S S Emergency repair of incarcerated/strangulated femoral A A/S S hernia using Cooper’s ligament (McVay) technique Open repair of ventral (incisional) hernia A S S Laparoscopic repair of ventral (incisional) hernia A A/S A/S Repair of parastomal hernia A A/S S Repair of lumbar hernia A A/S S Open repair of Spigelian hernia A A/S S Laparoscopic repair of Spigelian hernia A A S Emergency repair of obturator hernia A A/S S Emergency repair of fascial dehiscence/evisceration A S S Repair of hydrocele A S S Incision/drainage of abdominal wall abscess S S S Adrenal Procedures Laparoscopic adrenalectomy A A A/S

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the general surgical patient • Arrange appropriate follow-up care services for the general surgical patient

Page 2.2.12 Learning Objectives (Mandatory) – General Surgery – A-Service

¾ Communicator At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the general surgical patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the A-Service general surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the A-Service General Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the A- Service General Surgery rotation

¾ Collaborator At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals (e.g. nurses/ET nurses, nursing assistants, dieticians and physiotherapists) in the management of the general surgical patient • Work with others to assess, plan, provide and integrate care of the general surgical patient • Demonstrate leadership in the day-to-day running of resident/student team activities on the A- Service General Surgery rotation

¾ Manager At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing general surgical patients

Page 2.2.13 Learning Objectives (Mandatory) – General Surgery – A-Service

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings • Lead the A-Service team effectively and efficiently

¾ Health Advocate At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the general surgical patient • Identify the health needs of an individual patient • Identify opportunities for advocacy, health promotion and disease prevention (e.g. colorectal cancer screening)

¾ Scholar At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the A-Service General Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the A-Service General Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.2.14 Learning Objectives (Mandatory) – General Surgery – B-Service

2.3: GENERAL SURGERY – B-SERVICE

PREAMBLE The rotation on B-Service General Surgery concentrates on several focus areas, including hepatobiliary, colorectal and minimal access surgery in addition to a broad spectrum of general surgical conditions. The B-Service experience offers exposure to the clinical problems commonly seen by the practicing general surgeon on an elective and on an emergency basis.

GENERAL OBJECTIVES Upon completion of the B-Service General Surgery rotation, the General Surgery resident is expected to acquire the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies pertinent to the A-Service General Surgery rotation, including gender-related and ethnic perspectives. The resident is advised to review the Learning Objectives for General Surgery Residents on General Surgery Rotations in conjunction with these rotation-specific objectives.

SPECIFIC OBJECTIVES At the completion of the B-Service General Surgery rotation, the General Surgery resident will have acquired the following competencies and will function as:

¾ Medical Expert At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the B- Service General Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the B-Service General Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the following areas: o Breast and axilla o Upper gastrointestinal system o Lower gastrointestinal system o Biliary tract (see below) o Retroperitoneum o Spleen/pancreas o Inguinal/femoral • Physiology, including: o Gastrointestinal/function/motility o Biliary/bile composition and function (see below) o Spleen/hematopoietic system

Page 2.3.1 Learning Objectives (Mandatory) – General Surgery – B-Service

• Medical problems in the surgical patient, including: o Preoperative assessment o Preparation for specific operative interventions (e.g. bowel preparation for colorectal surgery) o Antimicrobial prophylaxis o Anticoagulation/thromboembolic prophylaxis o Corticosteroid management o Diabetes management • Conduct of a surgical procedure, including: o General principles o Specific operative interventions • Postoperative care, including: o Prevention and treatment of postoperative infections o Management of cardiac/hypertensive complications o Management of thromboembolic complications o Management of pulmonary complications o Management of endocrine/metabolic problems (e.g. diabetes) o Management of fluid and electrolyte/renal problems • Wound management and healing/biomaterials for hernia repair • Sepsis and surgical infections • Hemostasis and use of blood products • Fluid management and acid-base problems • Metabolic and nutritional care • Cancer, including: o Principles of neoplasia o Diagnosis and staging o Therapeutic options o Principles of chemotherapy o Principles of radiation oncology • Imaging for the general surgeon, including: o Plain x-rays o Contrast studies and interventional radiology o CT/colonography o Ultrasound/endoscopic ultrasound o MRI/MRCP o Nuclear medicine studies (scintigraphy) o PET • Diagnostic/therapeutic GI endoscopy, including: o Upper GI endoscopy o Colonoscopy/sigmoidoscopy o ERCP (see below) • Laboratory medicine for the general surgeon, including: o Hematology o Biochemistry o Microbiology o GI laboratory studies, including: ƒ Esophageal manometry/pH ƒ Anorectal manometry ¬ Acute Surgical Problems • Principles of early assessment and investigation in the acute abdomen, including: o Conditions associated with abdominal pain, including: ƒ Acute appendicitis ƒ Cholecystitis/biliary colic/choledocholithiasis/cholangitis ƒ Pancreatitis ƒ Peptic ulcer disease (with or without perforation)

Page 2.3.2 Learning Objectives (Mandatory) – General Surgery – B-Service

ƒ Gastroesophageal reflux ƒ Gastritis/duodenitis ƒ Diverticulitis ƒ Inflammatory bowel disease ƒ Enterocolitis ƒ Small intestinal obstruction ƒ Colonic obstruction ƒ Splenomegaly ƒ Mesenteric ischemia ƒ Leaking/ruptured abdominal aortic aneurysm ƒ Gynecologic conditions, including: à Ectopic pregnancy à Tubo-ovarian abscess à Salpingitis à Endometritis ƒ Genito-urinary conditions, including: à Urosepsis à Pyelonephritis à Ureterolithiasis à Testicular torsion ƒ Common non-surgical conditions that can present with abdominal pain, including: à Myocardial infarction à Pneumonia à Pleuritis à Hepatitis à Gastroenteritis à Mesenteric adenitis à Sickle cell crisis à Diabetic ketoacidosis à Herpes zoster à Nerve root compression à Myofascial syndrome ƒ Conditions causing abdominal pain in the immune-compromised patient, including: à Neutropenic enterocolitis à CMV enterocolitis o Investigations, including: ƒ Blood tests ƒ Diagnostic imaging ƒ Endoscopy/laparoscopy o Early management of patients with acute abdominal pain, including: ƒ Operative versus nonoperative approach • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common surgical emergencies, including: o Perforations of the upper gastrointestinal tract, including: ƒ Esophageal perforation ƒ Perforated peptic ulcer ƒ Perforated gastric lesions o Gastrointestinal hemorrhage, including: ƒ Acute non-variceal upper gastrointestinal bleeding ƒ Acute variceal upper gastrointestinal bleeding ƒ Hematobilia ƒ Aorto-enteric fistula ƒ Acute lower gastrointestinal bleeding

Page 2.3.3 Learning Objectives (Mandatory) – General Surgery – B-Service

o Pancreaticobiliary emergencies, including: ƒ Biliary colic/acute cholecystitis/acalculous cholecystitis ƒ The acutely jaundiced patient ƒ Choledocholithiasis/cholangitis ƒ Acute pancreatitis/necrotizing pancreatitis o Hepatic emergencies, including: ƒ Acute abscess ƒ Infected cyst o Small intestinal emergencies, including: ƒ Obstruction ƒ Mesenteric ischemia ƒ Inflammatory conditions, including: à Crohn’s disease à Radiation enteritis ƒ Meckel’s diverticulum ƒ Bleeding o Acute appendicitis/perforation/phlegmon o Colorectal emergencies, including: ƒ Colonic obstruction ƒ Intestinal pseudo-obstruction ƒ Acute colorectal bleeding ƒ Colonic perforation ƒ Volvulus, including: à Cecal volvulus à Sigmoid volvulus ƒ Acute diverticulitis, including the following complications: à Perforation à Abscess à Obstruction à Bleeding ƒ Emergencies related to colorectal malignancy ƒ Emergencies related to inflammatory bowel disease, including: à Ulcerative colitis à Crohn’s disease ƒ Emergencies related to pseudomembranous colitis ƒ Ischemic colitis ƒ Radiation proctocolitis o Anorectal emergencies, including: ƒ Ischiorectal/perianal abscess ƒ Acute anal fissure ƒ Acute hemorrhoid emergencies, including: à Thrombosis à Prolapse/gangrene à Bleeding ƒ Pilondal abscess ƒ Foreign body ƒ Fulminating sepsis/fasciitis/myonecrosis o Acute conditions related to hernias of the abdominal wall, groin (inguinal/femoral) and obturator foramen, including: ƒ Incarceration ƒ Strangulation ƒ Obstruction

Page 2.3.4 Learning Objectives (Mandatory) – General Surgery – B-Service

o Soft tissue infection, including: ƒ Cellulitis ƒ Abscess ƒ Fulminating sepsis, including: à Fasciitis à Myonecrosis à Fournier’s gangrene ¬ Non-Emergency Gastrointestinal/Colorectal Diseases • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of the following: o Gastroesophageal reflux disease/hiatus hernia/Barrett’s o Achalasia o Peptic ulcer disease/H pylori o Gastric neoplasia, including: ƒ GIST ƒ Adenocarcinoma ƒ Lymphoma/MALT o Inflammatory bowel disease, including: ƒ Ulcerative colitis/pelvic pouch procedure ƒ Crohn’s, including: à Gastroduodenal à Small intestine à Large intestine/anorectal o Gastrointestinal fistulas o Small intestinal neoplasia, including: ƒ Polyps ƒ GIST ƒ Adenocarcinoma ƒ Lymphoma ƒ Carcinoid tumour/carcinoid syndrome o Polyps of the colon and rectum, including: ƒ Classification ƒ Polyp syndromes/molecular genetic aspects ƒ Screening/surveillance ƒ Surgical options o Colorectal cancer, including: ƒ Molecular genetic aspects/HNPCC ƒ Staging ƒ Multidisciplinary management ƒ Screening/surveillance o Diverticular disease of the colon, including: ƒ Classification ƒ Non-emergency complications, including: à Colovesical fistula à Stricture à Colonic spasm o Motility disorders of the large intestine/constipation, including: ƒ Colonic inertia ƒ Pelvic outlet obstruction o Intestinal stomas, including: ƒ Ileostomy ƒ Colostomy

Page 2.3.5 Learning Objectives (Mandatory) – General Surgery – B-Service

o Anorectal disorders, including: ƒ Hemorrhoids ƒ Anal fissure/ulcer ƒ Anal fistula, including: à Classification à Salmon-Goodsall rule à Management options/approach ƒ Rectovaginal fistula ƒ Anal/perianal neoplasms, including: à High-grade squamous intraepithepial lesions (HSIL) à Squamous cell carcinoma of anal margin à Basal cell carcinoma of anal margin à AIN (Bowen’s disease) à Paget’s disease à Epidermoid carcinoma of anal canal à Malignant melanoma of anal canal ƒ Condylomata acuminata ƒ Dysfunction of the anorectum, including: à Incontinence à Pelvic floor dysfunction/solitary rectal ulcer syndrome/rectal procidentia ƒ Pilonidal disease ¬ Liver (Non-Emergency Problems) • Liver anatomy, including: o Lobar/segmental anatomy o Vascular anatomy o Microscopic anatomy, including: ƒ Functional unit ƒ Hepatocyte • Hepatic physiology, including: o Metabolism, including: ƒ Carbohydrate metabolism ƒ Lipid metabolism ƒ Protein metabolism ƒ Bilirubin metabolism ƒ Vitamin metabolism ƒ Drug/toxin metabolism o Bile formation/secretion o Coagulation o Reticuloendothelial system • Assessment of liver function • Liver imaging, including: o Ultrasound o CT o MRI • Interventional diagnostic radiology, including: o Needle biopsy o Angiography o CT arterial portography • Presentation, principles of assessment and diagnostic strategy in the patient presenting with a liver mass

Page 2.3.6 Learning Objectives (Mandatory) – General Surgery – B-Service

• Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common liver disorders, including: o Infectious diseases, including: ƒ Pyogenic abscess ƒ Amebic abscess ƒ Hydatid cyst o Benign neoplasms, including: ƒ Liver cell adenoma ƒ Focal nodular hyperplasia ƒ Hemangioma ƒ Hamartoma ƒ Simple cyst/polycystic liver disease o Malignant neoplasms, including: ƒ Hepatocellular carcinoma ƒ Metastatic tumours, including: à Colorectal tumours à Neuroendocrine tumours à Non-colorectal, non-neuroendocrine tumours • Principles of liver resection, including: o Indications/contraindications o Technical aspects of the following: ƒ Wedge resection ƒ Right hepatectomy ƒ Left hepatectomy ƒ Extended right hepatectomy (right trisegmentectomy) ƒ Left lateral segmentectomy ƒ Extended left hepatectomy (left trisegmentectomy) o Perioperative patient care o Complications of the above procedures o Expected outcomes • Non-resectional therapeutic interventions, including: o Percutaneous abscess/cyst drainage o Ablation of hepatic neoplasms, including: ƒ Embolization ƒ Radiofrequency ablation (RFA) o Hepatic artery catheterization for chemotherapy • Surgical complications of cirrhosis and portal hypertension, including: o Anatomy, physiology and pathophysiology of portal hypertension o Evaluation of the patient with cirrhosis o Principles of assessment and management of variceal hemorrhage, including: ƒ Endoscopic management ƒ Balloon tamponade ƒ Pharmacotherapy ƒ Transjugular intrahepatic portosystemic Shunt (TIPS) ƒ Portosystemic shunts ƒ Liver transplantation ¬ Biliary Tract • Biliary tract anatomy, including: o Extrahepatic biliary tract o Common anomalies/variations o Vascular anatomy

Page 2.3.7 Learning Objectives (Mandatory) – General Surgery – B-Service

• Biliary tract physiology, including: o Bile ducts o Gallbladder o Bile composition and function o Biliary motility • Bacteriology of the biliary tract/antibiotic selection • Biliary tract imaging, including: o Ultrasound/endoscopic ultrasound o CT o MRI/MRCP o Biliary scintigraphy o ERCP o Percutaneous transhepatic cholangiography • Interventional therapeutic radiology/endoscopy, including: o Percutaneous biliary drainage/stenting/lithotripsy o ERCP therapeutic techniques • Obstructive jaundice, including: o Differential diagnosis o Diagnostic evaluation/strategy o Principles of management • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common non-emergent biliary tract disorders, including: o Calculous biliary disease, including: ƒ Gallstone pathogenesis ƒ Diagnosis of gallbladder disease ƒ Laparoscopic/open cholecystectomy, including: à Indications à Technical considerations à Complications à Outcomes ƒ Choledocholithiasis ƒ Laparoscopic/open common bile duct exploration, including: à Indications à Technical considerations à Complications à Outcomes o Polypoid lesions of the gallbladder o Bile duct injury, including: ƒ Classification ƒ Approach to diagnosis/management ƒ Surgical/technical considerations o Choledochal cyst, including: ƒ Classification ƒ Approach to diagnosis/management ƒ Surgical/technical considerations o Gallbladder cancer o Cholangiocarcinoma, including: ƒ Classification ƒ Staging ƒ Surgical/technical considerations ƒ Palliative management

Page 2.3.8 Learning Objectives (Mandatory) – General Surgery – B-Service

¬ Pancreas • Pancreatic anatomy, including congenital anomalies • Pancreatic physiology, including: o Exocrine function o Endocrine function o Assessment of pancreatic exocrine/endocrine function • Pancreatic imaging, including: o Ultrasound/endoscopic ultrasound o CT o MRI/MRCP o Scintigraphy o Angiography/portal venous sampling o ERCP • Interventional therapeutic radiology/endoscopy, including: o Percutaneous cyst drainage o ERCP therapeutic techniques • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common non-emergent disorders of the pancreas, including: o Chronic pancreatitis, including: ƒ Approach to diagnosis/management ƒ Surgical/technical considerations ƒ Pain management strategies o Benign exocrine tumours o Pancreatic adenocarcinoma, including: ƒ Staging ƒ Pancreaticoduodenectomy, jncluding: à Indications/contraindications/resectability à Technical considerations ƒ Resectional surgery for tumours of the body/tail ƒ Palliative surgical management ƒ Chemoradiation therapy for palliation o Islet cell tumours, including: ƒ Insulinoma ƒ Gastrinoma/Zollinger-Ellison syndrome ƒ VIPoma (Verner-Morrison syndrome) ƒ Glucagonoma ƒ Somatostatinoma ƒ Multiple endocrine neoplasia (MEN) ¬ Non-Emergency Splenic Diseases • Operative indications for splenectomy, including: o Hypersplenism o Autoimmune/erythrocyte disorders o Cysts/tumours o Diagnostic o Iatrogenic o Incidental • Laparoscopic/open splenectomy, including: o Indications o Technical considerations o Complications o Expected outcomes

Page 2.3.9 Learning Objectives (Mandatory) – General Surgery – B-Service

¬ Minimal Access Surgery • Basic principles of minimal access surgery • Indications, technical considerations, complications and expected outcomes for the following specific minimal access operative procedures performed on the B-Service General Surgery rotation: o Biliary tract procedures, including: ƒ Cholecystectomy ƒ Common bile duct exploration o Foregut procedures, including: ƒ Antireflux operations ƒ Heller myotomy for achalasia ƒ Gastric resection ƒ Gastroenterostomy o Colorectal procedures, including: ƒ Appendectomy ƒ Ileocolonic resection ƒ Colectomy ƒ Anterior resection ƒ Abdominoperineal resection ƒ Repair of rectal prolapse o Splenectomy o Adrenalectomy o Hernia repair, including: ƒ Groin hernia ƒ Ventral hernia ƒ Spigelian hernia

With respect to the above outline of cognitive objectives: • The PGY-1 resident and the junior resident will be able to outline the initial management of the listed conditions • The senior/chief resident will be able to describe the listed conditions beyond initial management, including operative procedures, perioperative considerations, complications, expected outcomes and follow-up

Perform a complete and appropriate assessment of the general surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the general surgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the general surgical patient, including appropriate and expeditious patient disposition in the acute care setting • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the B-Service General Surgery rotation • Ensure appropriate informed consent is obtained for therapies

The PGY-1 resident and the junior resident will be able to: • Perform many of the above clinical skills • Initiate well thought-out and appropriate management strategies; will require corroboration or modification by a more senior individual

Page 2.3.10 Learning Objectives (Mandatory) – General Surgery – B-Service

The senior/chief resident will be able to: • Perform the above clinical skills • Formulate management strategies completely • Coordinate team members and consultants in the development, documentation and execution of clear and integrated management plans

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the B-Service General Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the B-Service General Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the B-Service General Surgery rotation

Having completed the B-Service General Surgery rotation, the General Surgery resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Operative Procedures PGY-1 Junior Senior/Chief General Diagnostic and Therapeutic Procedures Arterial puncture S S S Venipuncture S S S Venous cutdown S S S Central venous catheter insertion S S S Insertion/removal of venous access reservoir (Portacath) S S S Removal of peritoneal dialysis catheter S S S Urinary catheter insertion S S S Nasogastric tube insertion S S S Integumentary System Incision/drainage of subcutaneous abscess S S S Excision of subcutaneous lesions S S S Hematologic/Lymphatic Biopsy of enlarged lymph nodes (cervical; axillary; inguinal; A S S scalene) Open splenectomy A A/S S Laparoscopic splenectomy A A A/S Endoscopic Procedures Flexible sigmoidoscopy NA S S Rigid sigmoidoscopy NA S S Percutaneous endoscopic gastrostomy (PEG) NA S S Diagnostic laparoscopy A S S Esophageal Procedures Laparoscopic esophagomyotomy (Heller myotomy) A A A/S Open transabdominal hiatus hernia repair/fundoplication A A A/S

Page 2.3.11 Learning Objectives (Mandatory) – General Surgery – B-Service

Operative Procedures PGY-1 Junior Senior/Chief Laparoscopic transabdominal hiatus hernia A A A/S repair/fundoplication Esophagogastrectomy A A A/S Gastroduodenal Procedures Open wedge excision of gastric GIST/other lesions A A S Laparoscopic excision of gastric GIST/other lesions A A A/S Open partial gastric resection with Billroth I/Billroth II/Roux- A A S en-y reconstruction Laparoscopic partial gastric resection with Billroth I/Billroth A A A/S II/Roux-en-y reconstruction Open total gastrectomy A A S Open gastroenterotomy A S S Laparoscopic gastroenterotomy A A A/S Open surgical gastrostomy techniques A A/S S Laparoscopic surgical gastrostomy techniques A A A/S Open pyloroplasty A A/S S Laparoscopic pyloroplasty A A A/S Open gastrotomy and oversewing of bleeding gastric A A S ulcer/erosion Duodenotomy/pylorotomy and oversewing of bleeding A A/S S duodenal ulcer Vagotomy techniques for peptic ulcer A A A/S Open omental patch of perforated peptic ulcer A S S Laparoscopic omental patch of perforated peptic ulcer A A S Laparoscopic gastric bypass/Roux-en-y gastrojejunostomy A A A for morbid obesity Small Intestinal Procedures Open enterostomy (feeding/loop) A S S Laparoscopic enterostomy A A S Closure of enterostomy A A S Laparotomy and enterolysis for intestinal obstruction A A/S S Open small intestinal resection/anastomosis A A/S S Laparoscopic small intestinal resection/anastomosis A A A/S Open resection of Meckel’s diverticulum A A/S S Laparoscopic resection of Meckel’s diverticulum A A S Open enteroanatomosis A A/S S Laparoscopic enteroanastomosis A A A/S Stricturoplasty for Crohn’s disease A A/S S Colon and Rectal Procedures Open appendectomy A/S S S Laparoscopic appendectomy A S S Open colostomy (end/loop) A A/S S Laparoscopic colostomy A A A/S Colostomy closure A A/S S Open colonic resection/anastomosis (segmental/subtotal) A A/S S Open sigmoid resection with Hartmann for perforated A A/S S diverticulitis Laparoscopic colonic resection (segmental/subtotal) A A/S S Open anterior resection with total mesorectal excision A A/S S (TME)

Page 2.3.12 Learning Objectives (Mandatory) – General Surgery – B-Service

Operative Procedures PGY-1 Junior Senior/Chief Laparoscopic anterior resection with total mesorectal A A A/S excision (TME) Open abdominoperineal resection with total mesorectal A A/S S excision (including perineal portion of the procedure) Laparoscopic-assisted abdominoperineal resection with A A A/S total mesorectal excision (including perineal portion of the procedure Total proctocolectomy with Brooke ileostomy for colitis A A S Pelvic pouch procedure with stapled j-pouch for colitis A A A/S Pelvic pouch procedure with total colectomy/rectal A A A/S mucosectomy and stapled j-pouch/handsewn ileoanal anastomosis for FAP/dysplasia Open takedown of Hartmann A A/S S Laparoscopic takedown of Hartmann A A A/S Transanal excision of rectal polyp A S S Laparoscopic repair of rectal prolapse A A A/S Perineal rectosigmoidectomy for rectal prolapse A A/S S Anorectal Procedures Excision of thrombosed hemorrhoid S S S Hemorrhoid banding S S S Hemorrhoid injection S S S Hemorrhoidectomy A A/S S Lateral internal sphincterotomy for anal fissure A A/S S Excision of anal fissure A A/S S Incision/drainage of perianal abscess S S S Incision/drainage of ischiorectal abscess S S S Anal dilatation S S S Anal sphincter repair A A A/S Excision/fulguration of condylomata Acuminata A A/S S Anal fistulotomy techniques, including: A A/S S • Probing of fistula tract • Seton placement • Mucosal advancement flap • Fistula plug placement Anoplasty with v-y mucosal advancement flap A A/S S Excision and mapping of AIN/Bowen’s disease A S S Incision/drainage of pilonidal abscess S S S Excision of pilonidal sinus disease A S S Excision of hidradenitis suppurativa A S S Repair of rectovaginal fistula with mucosal advancement A A S flap Liver Procedures Open liver biopsy A S S Laparoscopic liver biopsy A A/S S Wedge excision of liver lesion A A/S S Left lateral segmentectomy A A/S S Left hepatic lobectomy A A A/S Left trisegmentectomy A A A/S Right hepatic lobectomy A A A/S Right trisegmentectomy A A A/S Open radiofrequency ablation of liver lesion A A A/S Open decompression/management of liver abscess/cyst A A S

Page 2.3.13 Learning Objectives (Mandatory) – General Surgery – B-Service

Operative Procedures PGY-1 Junior Senior/Chief Laparoscopic decompression/management of liver A A A/S abscess/cyst Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and cholangiography A S S Open cholecystostomy A S S Laparoscopic cholecystostomy A S S Open common bile duct exploration A A S Laparoscopic common bile duct exploration A A A/S Biliary-intestinal anastomosis for tumour/stricture/bile duct A A S injury Operative management of choledochal cyst/neoplasm A A A/S Pancreatic Procedures Drainage of pancreatic abscess A A/S S Pancreatic necrosectomy A A S Open drainage of pancreatic pseudocyst by anastomosis to A A/S S stomach or intestine Laparoscopic drainage of pancreatic pseudocyst by A A A/S anastomosis to stomach or intestine Puestow procedure A A S Distal pancreatectomy A A/S A/S Hernia and Abdominal Wall Procedures Elective open repair of inguinal hernia using tension-free A S S mesh technique Elective laparoscopic repair of inguinal hernia A A/S S Emergency repair of incarcerated/strangulated inguinal A A/S S hernia using Cooper’s ligament (McVay) technique Elective open repair of femoral hernia using tension-free A S S mesh technique Elective laparoscopic repair of femoral hernia A A/S S Emergency repair of incarcerated/strangulated femoral A A/S S hernia using Cooper’s ligament (McVay) technique Open repair of ventral (incisional) hernia A S S Laparoscopic repair of ventral (incisional) hernia A A/S A/S Repair of parastomal hernia A A/S S Repair of lumbar hernia A A/S S Open repair of Spigelian hernia A A/S S Laparoscopic repair of Spigelian hernia A A S Emergency repair of obturator hernia A A/S S Emergency repair of fascial dehiscence/evisceration A S S Repair of hydrocele A S S Incision/drainage of abdominal wall abscess S S S Adrenal Procedures Laparoscopic adrenalectomy A A A/S

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the general surgical patient • Arrange appropriate follow-up care services for the general surgical patient

Page 2.3.14 Learning Objectives (Mandatory) – General Surgery – B-Service

¾ Communicator At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the general surgical patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the B-Service general surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the B-Service General Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the B- Service General Surgery rotation

¾ Collaborator At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals (e.g. nurses/ET nurses, nursing assistants, dieticians and physiotherapists) in the management of the general surgical patient • Work with others to assess, plan, provide and integrate care of the general surgical patient • Demonstrate leadership in the day-to-day running of resident/student team activities on the B- Service General Surgery rotation

¾ Manager At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing general surgical patients

Page 2.3.15 Learning Objectives (Mandatory) – General Surgery – B-Service

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings • Lead the B-Service team effectively and efficiently

¾ Health Advocate At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the general surgical patient • Identify the health needs of an individual patient • Identify opportunities for advocacy, health promotion and disease prevention (e.g. colorectal cancer screening)

¾ Scholar At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the B-Service General Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the B-Service General Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.3.16 Learning Objectives (Mandatory) – Community Surgery

2.4: GENERAL SURGERY – COMMUNITY SURGERY

PREAMBLE The Community General Surgery rotation offers the General Surgery resident the opportunity to experience general surgical practice in a community setting. This rotation has both urban and rural sites available. The resident should contact the Surgical Education Office sufficiently in advance in order to secure his/her desired site.

GENERAL OBJECTIVES Upon completion of the Community General Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills, decision-making capabilities and attitudes essential to the roles of specialist in General Surgery practiced in the community • Appreciate the features of General Surgery practiced in the community that make it distinct from tertiary General Surgery

SPECIFIC OBJECTIVES At the completion of the Community General Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Communicator (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Collaborator (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Manager (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Health Advocate (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Scholar (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

¾ Professional (see Learning Objectives for General Surgery Residents on General Surgery Rotations)

Page 2.4.1 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

2.5: GENERAL SURGERY – GOLD SERVICE: TRAUMA & ACUTE CARE

PREAMBLE The Trauma Acute Care Surgery (Gold) Service is designated to provide the organization necessary to deliver immediate care to the acutely ill and injured patients. This rotation is intended to provide General Surgery residents with the opportunity for concentrated exposure to major trauma and acute general surgery cases beginning with presentation in the emergency department. The rotation emphasizes clinical assessment, physiologic stabilization, diagnostic evaluation and prioritized management along a continuum of care beginning in the emergency department and culminating in hospital discharge and early follow-up. The Trauma Acute Care Surgery (Gold) Service experience offers unparalleled exposure to the clinical problems commonly seen by the practicing general surgeon. Each new case provides the opportunity to challenge ability and to further competency and prompts the resident to develop a well-informed, evidence-based and systematic approach to common serious conditions.

GENERAL OBJECTIVES Upon completion of the Trauma Acute Care Surgery (Gold) rotation, the General Surgery resident is expected to acquire the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies pertinent to the Trauma Acute Care Surgery Service rotation, including gender-related and ethnic perspectives. The resident is advised to review the Learning Objectives for General Surgery Residents on General Surgery Rotations in conjunction with these rotation-specific learning objectives. The junior resident should strive to become competent as a team leader in the management of trauma and acute care cases. The senior/chief resident should aim to demonstrate complete competence as a consultant in General Surgery, including authoritative team leadership in the management of trauma and the provision of thoughtful, appropriate and complete management of trauma and acute care surgical cases. Furthermore, he/she is expected to develop and demonstrate the ability to organize and manage this complex and active Service such that quality patient care is consistently maintained. This Service challenges the resident to prioritize continually and to coordinate effectively and simultaneously the input of many consulting professionals. The task demands professionalism in every regard. Finally, the senior/chief resident is charged with contributing to the pedagogical experience of more junior trainees by initiating discussions around appropriate clinical cases on a regular basis.

SPECIFIC OBJECTIVES At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will have acquired the following competencies and will function as:

¾ Medical Expert At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Trauma Acute Care Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Trauma Acute Care Surgery rotation

Page 2.5.1 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Trauma • Biomechanics of injury • Principles of triage • Appropriate measures for the disposition and safe transport of the trauma patient • Initial evaluation of the trauma patient, including: o Airway management with cervical spine protection, including: ƒ Orotracheal and nasotracheal intubation ƒ Cricothyroidotomy for airway obstruction ƒ Tracheostomy for airway obstruction o Breathing and ventilation, including principles of management of life-threatening chest injuries o Principles of circulatory assessment and management, including: ƒ Recognition, evaluation and management of the common causes of hypoperfusion and shock (hypovolemic/hemorrhagic, septic, neurogenic and cardiogenic) in the trauma patient ƒ Hemorrhage control ƒ Principles of vascular/intravenous access ƒ Principles of fluid resuscitation and use of blood components ƒ Types, etiology and prevention of coagulopathies typically found in patients with massive hemorrhage o Principles of neurologic assessment, including: ƒ Glasgow Coma Scale ƒ Causes of altered mental status in the trauma patient o Principles and conduct of the secondary survey in the trauma patient o Principles and methods of monitoring the trauma patient o Indications for and interpretation of diagnostic imaging and other diagnostic studies in the trauma patient, including: ƒ Plain x-rays ƒ Contrast x-ray studies ƒ Ultrasound (FAST/echo) ƒ CT ƒ Angiography ƒ Diagnostic peritoneal lavage (DPL) ƒ Endoscopy/laparoscopy • Indications for consultation of other surgical disciplines in the management of the trauma patient • Indications for and principles of preparation for immediate/early surgical intervention in the trauma patient • Principles of assessment and management of specific injuries, including: o Head trauma, including: ƒ Glasgow Coma Scale ƒ Intracranial pressure monitoring/management ƒ Subdural hematoma ƒ Extradural hematoma ƒ Diffuse axonal injury ƒ Basilar skull fractures/CSF leaks o Spine and spinal cord trauma, including: ƒ Mechanism of injury ƒ Level of injury ƒ Use of steroids ƒ Principles of immobilization ƒ Management of spinal shock

Page 2.5.2 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

o Neck trauma, including: ƒ Assessment of penetrating injuries to the neck with reference to division into Zones I, II and III and indications for surgical exploration ƒ Surgical exposure of the great vessels in the thoracic inlet and neck ƒ Clinical manifestations and principles of management of injuries to neck structures, including: à Great vessels à Trachea and larynx à Pharynx and esophagus à Thyroid à Salivary gland à Major nerves à Skin and soft tissues o Maxillofacial trauma o Ocular trauma o Thoracic trauma, including: ƒ Tension pneumothorax ƒ Open pneumothorax ƒ Flail chest ƒ Massive hemothorax/hemothorax, including: à Technique of chest tube insertion à Indications for thoracotomy ƒ Cardiac tamponade secondary to penetrating injury, including: à Pericardiocentesis à Indications for and technique of emergency room thoracotomy ƒ Simple pneumothorax ƒ Pulmonary contusion ƒ Tracheobronchial disruption ƒ Blunt cardiac injury ƒ Traumatic aortic disruption ƒ Traumatic diaphragmatic injury ƒ Esophageal trauma ƒ Mediastinal traversing injuries o Abdominal trauma (blunt/penetrating), including: ƒ Gastric trauma ƒ Duodenal trauma, including: à Classification/management based on Duodenal Injury Severity Scale à Association with trauma to adjacent organs à Principles and technical aspects of operative management ƒ Pancreatic trauma, including: à Classification/management based on Pancreatic Injury Severity Scale à Principles and technical aspects of operative management à Complications, including pancreatic fistula ƒ Small intestinal trauma ƒ Colonic/rectal trauma, including: à Principles and technical aspects of operative repair à Primary repair versus diversion à Complications ƒ Liver/biliary tract/gallbladder trauma, including: à Classification based on Liver Injury Severity Scale à Operative versus nonoperative management à Principles and technical aspects of operative management à Management of associated vena cava injury à Management of portal venous injury

Page 2.5.3 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

ƒ Splenic trauma, including: à Classification/management based on Spleen Injury Severity Scale à Operative versus nonoperative management à Principles and technical aspects of operative management à Complications, including overwhelming post splenectomy infection ƒ Urinary tract/penetrating flank trauma, including: à Renal injury, including classification and associated vascular injury à Ureteral injury à Intraperitoneal/extraperitoneal bladder injury and associated pelvic fractures à Urethral trauma and associated pelvic fractures ƒ Abdominal vascular trauma, including: à Injury to abdominal aorta and branches à Vena cava injury ƒ Principles and technique of damage control surgery in the trauma patient with devastating injuries ƒ Abdominal compartment syndrome, including: à Clinical presentation/physiologic consequences à Principles of assessment/monitoring à Principles and technical aspects of surgical management o Emergent care of musculoskeletal and soft tissue trauma, including: ƒ Major extremity trauma, including: à Open versus closed fractures à Prevention/assessment/management of compartment syndromes à Concepts of immobilization (splinting/internal fixation) à Hemorrhage control à Commonly associated vascular injury à Associated nerve injury ƒ Pelvic fractures, including: à Associated urinary tract injury à Associated vascular injury/hemorrhage control o Thermal injury, including: ƒ Initial assessment/management of major burns, including: à Estimation of total body surface burn and burn depth à Principles/management of fluid resuscitation and monitoring for adequacy of resuscitation à Assessment/management of inhalation injury and carbon monoxide poisoning à Principles of wound coverage/skin grafting à Indications for and technique of escharotomy ƒ Initial assessment/management of cold injury o Indications for and principles of antibiotic usage in the trauma patient o Tetanus prophylaxis in the trauma patient o DVT prophylaxis in the trauma patient o Management of myoglobinuria in the trauma patient ¬ Acute Surgical Problems • Principles of early assessment and investigation in the acute abdomen, including: o Conditions associated with abdominal pain, including: ƒ Acute appendicitis ƒ Cholecystitis/biliary colic/choledocholithiasis/cholangitis ƒ Pancreatitis ƒ Peptic ulcer disease (with or without perforation) ƒ Gastroesophageal reflux ƒ Gastritis/duodenitis ƒ Diverticulitis ƒ Inflammatory bowel disease ƒ Enterocolitis ƒ Small intestinal obstruction

Page 2.5.4 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

ƒ Colonic obstruction ƒ Splenomegaly ƒ Mesenteric ischemia ƒ Leaking/ruptured abdominal aortic aneurysm ƒ Gynecologic conditions, including: à Ectopic pregnancy à Ovarian cyst (torsion; hemorrhage; rupture) à Tubo-ovarian abscess à Salpingitis à Endometritis ƒ Genito-urinary conditions, including: à Urosepsis à Pyelonephritis à Ureterolithiasis à Testicular torsion ƒ Common non-surgical conditions that can present with abdominal pain, including: à Myocardial infarction à Pneumonia à Pleuritis à Hepatitis à Gastroenteritis à Mesenteric adenitis à Sickle cell crisis à Diabetic ketoacidosis à Herpes zoster à Nerve root compression à Myofascial syndrome ƒ Conditions causing abdominal pain in the immune-suppressed patient, including: à Neutropenic enterocolitis à CMV enterocolitis à Acute graft rejection o Investigations, including: ƒ Blood tests ƒ Diagnostic imaging ƒ Endoscopy/laparoscopy o Early management of patients with acute abdominal pain, including: ƒ Operative versus nonoperative approach • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common surgical emergencies, including: o Perforations of the upper gastrointestinal tract, including: ƒ Esophageal perforation ƒ Perforated peptic ulcer ƒ Perforated gastric lesions o Gastrointestinal hemorrhage, including: ƒ Acute non-variceal upper gastrointestinal bleeding ƒ Acute variceal upper gastrointestinal bleeding ƒ Hematobilia ƒ Aorto-enteric fistula ƒ Acute lower gastrointestinal bleeding o Pancreaticobiliary emergencies, including: ƒ Biliary colic/acute cholecystitis/acalculous cholecystitis ƒ The acutely jaundiced patient ƒ Choledochollithiasis/acute cholangitis ƒ Acute pancreatitis

Page 2.5.5 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

o Hepatic emergencies, including: ƒ Abscess ƒ Infected cyst o Small intestinal emergencies, including: ƒ Obstruction ƒ Mesenteric ischemia ƒ Inflammatory conditions, including: à Crohn’s disease à Radiation enteritis ƒ Meckel’s diverticulum ƒ Bleeding o Acute appendicitis/perforation/phlegmon o Colorectal emergencies, including: ƒ Colonic obstruction ƒ Intestinal pseudo-obstruction ƒ Acute colorectal bleeding ƒ Colonic perforation ƒ Volvulus, including: à Cecal volvulus à Sigmoid volvulus ƒ Acute diverticulitis ƒ Emergencies related to colorectal malignancy ƒ Emergencies related to inflammatory bowel disease, including: à Ulcerative colitis à Crohn’s disease ƒ Emergencies related to pseudomembranous colitis ƒ Ischemic colitis o Anorectal emergencies, including: ƒ Ischiorectal/perianal abscess ƒ Acute anal fissure ƒ Acute hemorrhoid emergencies,including: à Thrombosis à Prolapse/gangrene à Bleeding ƒ Pilonidal abscess ƒ Foreign body ƒ Fulminating sepsis/fasciitis/myonecrosis o Acute conditions related to hernias of the abdominal wall, groin (inguinal/femoral) and obturator foramen, including: ƒ Incarceration ƒ Strangulation ƒ Obstruction o Soft tissue infection, including: ƒ Cellulitis ƒ Abscess ƒ Fulminating sepsis, including: à Fasciitis à Myonecrosis à Fournier’s gangrene

With respect to the above outline of cognitive objectives: • The PGY-1 resident and the junior resident will be able to outline the initial management of the listed conditions • The senior/chief resident will be able to describe the listed conditions beyond initial management, including operative procedures, perioperative considerations, complications, expected outcomes and follow-up

Page 2.5.6 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

Perform a complete and appropriate assessment of the trauma/acute care patient • Elicit a history that is relevant, concise and accurate and in the case of the trauma patient includes assessment of mechanism of injury • Perform a focused physical examination that is relevant and accurate and in the case of the trauma patient includes initial assessment (primary/secondary survey) • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the trauma and acute care problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the trauma/acute care patient, including appropriate and expeditious patient disposition • Triage and organize care of multiple casualty victims simultaneously • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Trauma Acute Care Surgery (Gold) Service rotation, including a thorough and expeditious trauma resuscitation as per ATLS guidelines • Ensure appropriate informed consent is obtained for therapies

The PGY-1 resident and the junior resident will be able to: • Perform many of the above clinical skills • Initiate well thought-out and appropriate management strategies; will require corroboration or modification by a more senior individual

The senior/chief resident will be able to: • Perform the above clinical skills • Formulate management strategies completely • Coordinate team members and consultants in the development, documentation and execution of clear and integrated management plans

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Trauma Acute Care Surgery (Gold) Service rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Trauma Acute Care Surgery (Gold) Service rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base of all operative procedures performed on the Trauma Acute Care Surgery (Gold) Service rotation

Having completed the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Page 2.5.7 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

Operative Procedures PGY-1 Junior Senior/Chief Trauma Procedures Initial Assessment and Resuscitation Procedures Arterial puncture S S S Venipuncture S S S Venous cutdown S S S Central venous catheter insertion S S S Endotracheal intubation S S S Urinary catheter insertion S S S Suprapubic catheter insertion A S S Nasogastric/orogastric tube insertion Suture of laceration S S S Advanced Airway Management Cricthyroidotomy A/S S S Tracheostomy A S S Head and Neck Trauma Flexible esophagoscopy A A/S S Flexible bronchoscopy A A/S S Surgical exposure for control of a major vascular injury in A A S Zone II of the neck Thoracic Trauma Needle decompression for tension pneumothorax S S S Chest tube insertion for chest trauma S S S Pericardiocentesis for cardiac tamponade S S S Emergency room thoracotomy for penetrating cardiac injury A A S and cardiac arrest Abdominal Trauma Procedures Diagnostic peritoneal lavage (DPL) S S S Focused Assessment with Sonography for Trauma (FAST) A A A/S Trauma laparotomy, including: A S S • Midline incision • Four quadrant packing • Closure Damage control laparotomy A A/S S Control of major abdominal vascular injury A A/S S Repair/control of liver injury, including: A A S • Suture of laceration • Packing for bleeding • Resection Pancreatic resection for trauma A A/S A/S Pyloric exclusion for duodenal/pancreatic injury A A/S S Splenectomy/splenic salvage for trauma A A/S S Repair of acute diaphragmatic injury A A/S S Repair of gastrointestinal injuries A A/S S Intestinal resection for trauma A A/S S Colostomy/ileostomy for trauma A A/S S Repair of bile duct injury using t-tube A A S Biliary-intestinal anastomosis for bile duct injuries A A S

Page 2.5.8 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

Operative Procedures PGY-1 Junior Senior/Chief Acute Care Procedures Integumentary System Incision/drainage of subcutaneous abscess S S S Foreign body removal S S S Breast Incision/drainage of breast abscess S S S Endoscopic Procedures Esophagogastroduodenoscopy NA S S Colonoscopy NA S S Flexible sigmoidoscopy NA S S Rigid sigmoidoscopy S S S Endoscopic injection therapy NA S S Endoscopic banding for varices NA S S Hemorrhoid banding S S S Endoscopic thermal techniques for bleeding NA S S Endoscopic detorsion of sigmoid volvulus NA S S Diagnostic laparoscopy A S S Gastroduodenal Procedures Partial gastric resection with Billroth I/Billroth II/Roux-en-y A A/S S reconstruction for bleeding/perforation/obstruction Total gastrectomy for bleeding A A S Gastrotomy and oversewing of bleeding gastric ulcer A A/S S Duodenotomy/pylorotomy and oversewing of bleeding A A/S S duodenal ulcer Truncal vagotomy for bleeding peptic ulcer A A A/S Omental patch of perforated peptic ulcer A S S Small Intestinal Procedures Laparotomy and enterolysis for intestinal obstruction Small intestinal resection/anastomosis A S S Resection of Meckel’s diverticulum A S S Enteroanastomosis A S S Colon and Rectal Procedures Open appendectomy A/S S S Laparoscopic appendectomy A A/S S Colostomy (end/loop) A A/S S Colonic resection (segmental/subtotal) with anastomosis or A A/S S ostomy Sigmoid resection with Hartmann for perforated A A/S S diverticulitis Anorectal Procedures Excision of thrombosed hemorrhoid S S S Hemorrhoidectomy A A/S S Hemorrhoid banding S S S Hemorrhoid injection S S S Lateral internal sphincterotomy for anal fissure A A/S S Incision/drainage of perianal abscess S S S Incision/drainage of ischiorectal abscess S S S Incision/drainage of pilonidal abscess S S S Liver Procedures Open decompression/management of liver abscess/cyst A A/S S

Page 2.5.9 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

Operative Procedures PGY-1 Junior Senior/Chief Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and cholangiography A S S Open cholecystostomy A S S Laparoscopic cholecystostomy A S S Open common bile duct exploration A A S Biliary-intestinal anastomosis A A S Pancreatic Procedures Drainage of pancreatic abscess A A/S S Pancreatic necrosectomy for necrotizing pancreatitis A A/S S Hernia and Abdominal Wall Procedures Emergency repair of incarcerated/strangulated inguinal A A/S S hernia using Cooper’s ligament (McVay) technique Emergency repair of incarcerated/strangulated femoral A A/S S hernia using Cooper’s ligament (McVay) technique Emergency repair of incarcerated/strangulated ventral A A/S S hernia Emergency repair of obturator hernia A A/S S Emergency repair of fascial dehiscence/evisceration A S S Incision/drainage of abdominal wall abscess S S S

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the trauma/acute care surgical patient • Arrange appropriate follow-up care services for the trauma/acute care surgical patient

¾ Communicator At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the trauma/acute care surgical patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the trauma/acute care surgical patient and family, colleagues and other professionals in a humane and understandable manner

Page 2.5.10 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the trauma/acute care surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Trauma Acute Care Surgery (Gold) Service rotation • Effectively present verbal reports of clinical encounters and medical information during the Trauma Acute Care Surgery (Gold) Service rotation

¾ Collaborator At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the trauma/acute care surgical patient • Work with others to assess, plan, provide and integrate care of the trauma/acute care surgical patient • Demonstrate leadership on the Trauma Acute Care Surgery (Gold) Service in general and in the trauma team in particular

¾ Manager At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing trauma/acute care surgical patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings • Lead the trauma team effectively and efficiently

¾ Health Advocate At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Respond to the needs of the trauma/acute care surgical patient • Identify the health needs of an individual patient • Identify opportunities for advocacy, health promotion and disease prevention (e.g. promotion of seat belt and helmet usage/trauma prevention)

Page 2.5.11 Learning Objectives (Mandatory) – General Surgery – Gold Service: Trauma & Acute Care

¾ Scholar At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the trauma/acute care evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Trauma Acute Care Surgery (Gold) Service • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Trauma Acute Care Surgery (Gold) Service rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.5.12 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

2.6: GENERAL SURGERY – GREEN SERVICE: SURGICAL ONCOLOGY

PREAMBLE The Surgical Oncology (Green) Service sees approximately fifty new cancer referrals and two hundred fifty follow-up patients each month. The Service emphasizes multi-disciplinary management of the cancer patient.

GENERAL OBJECTIVES Upon completion of the rotation in Surgical Oncology (Green) Service, the General Surgery resident is expected to acquire the knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies pertinent to the Surgical Oncology rotation, including gender-related, cultural and ethnic perspectives. The resident is advised to review the Learning Objectives for General Surgery Residents on General Surgery Rotations in conjunction with these rotation-specific learning objectives.

SPECIFIC OBJECTIVES At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will have acquired the following competencies and will function as:

¾ Medical Expert At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Surgical Oncology rotation • Apply knowledge of the clinical, socio-behavioral and fundamental biomedical sciences relevant to the Surgical Oncology rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Breast Diseases • Definition of neoplasm, abscess and hyperplasia • Distinguishing benign from malignant neoplasms • Classification of breast neoplasm (benign and malignant) • Physical characteristics of breast cancer • Risk factors for breast cancer • Age-related variations in presentation profile for breast cancer and the differential diagnosis • Options available for breast screening • Initial assessment of a woman with: o A breast mass o Nipple discharge o Recent nipple retraction o Breast pain o Diffuse nodular breast tissue o Isolated axillary lymphadenopathy • Assessment and management of a woman with an abnormal mammogram

Page 2.6.1 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

• The clinical presentation, assessment and care of a woman with: o Ductal carcinoma in-situ o Lobular carcinoma in-situ o Atypical hyperplasia • The clinical presentation, assessment and management of a male with gynecomastia • The clinical presentation, assessment and management of: o Acute breast cellulites/abscess o Chronic cellulites with sinus formation o Macrocystic disease o Fibroadenoma o Duct ectasia • The indications for and the complications associated with the following procedures: o Fine needle aspiration biopsy o Core needle biopsy (true-cut) o Excision biopsy o Needle localization biopsy o Incision and drainage o Segmental mastectomy (lumpectomy) o Total mastectomy o Subcutaneous mastectomy o Axillary node biopsy o Sentinel lymph node biopsy o Axillary lymph node dissection • Detailed description of each of the above procedures with reference to: o Selection of the incision o Sequence of steps in the operation o Normal anatomic relations o Possible extension of the operation o Specific technical problems o Specimen handling o Expected outcomes/consequences as distinct from complications • The role for and the technical aspects of radiotherapy for breast cancer • Breast reconstruction options available for women • Advantages and disadvantages of immediate versus delayed breast reconstruction • The controversies surrounding the use of breast implants ¬ Melanoma • The clinical characteristics of a melanoma • The characteristics of: o Superficial spreading melanoma o Nodular melanoma o Melanoma in-situ o Acral lentiginous melanoma • The hereditary aspects of melanoma: o FAMM syndrome o Dysplastic nevi • The etiology of melanoma • The public education aspects of melanoma detection and prevention • Biopsy techniques acceptable for melanoma diagnosis and staging • The staging of melanoma • The appropriate resection margins for melanoma • The efficacy of elective lymph node dissection for melanoma • The options for therapy for recurrent and metastatic melanoma, including management of locoregional and in-transit metastases

Page 2.6.2 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

¬ Lymphoma • Definition of lymphoma • Classification of lymphoma as follows: o Hodgkin’s lymphoma o Non-Hodgkin’s lymphoma • The selection of lymph nodes, handling of tissue and tests required to optimally assess a patient with suspected lymphoma • Hodgkin’s lymphoma with respect to the following: o Histologic classification system o Staging system o Staging techniques o Indications and extent of staging laparotomy o Principles of therapy: ƒ Role of radiotherapy ƒ Role of chemotherapy ƒ Treatment planning based on histology and stage • Non-Hodgkin’s lymphoma with respect to the following: o Characteristic clinical features o Staging system o Staging techniques o Features, including recurrence patterns, surgical management, multimodality care, curability and optional procedures and techniques for extra-nodal locations of disease: ƒ Paranasal sinuses ƒ Parotid glands ƒ Thyroid ƒ Mediastinum ƒ Stomach ƒ Ileum ƒ Rectum ƒ Retroperitoneum o Principles of therapy: ƒ Role of chemotherapy ƒ Role of radiotherapy ƒ Role of surgery for primary cure ¬ Sarcoma • Definition of sarcoma • Classifification of sarcoma • Classifification of benign soft tissue tumours • The clinical presentation of a patient with a soft tissue tumour, including: o Typical physical features o Expected clinical course o Common sites of recurrence • Diagnostic approach to the patient with sarcoma, including: o Clinical examination o Imaging studies o Additional staging procedures o Initial biopsy

Page 2.6.3 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

• The principles of limb-sparing sarcoma management, including: o Approach to surgical resection: ƒ Wide excision ƒ Compartment resection ƒ Immediate revascularization ƒ Soft tissue reconstruction o Use of adjuvant or combined radiotherapy o Role of chemotherapy o Adequacy of margins • The staging system, including: o Importance of grade o Importance of tumour size • The management of pulmonary metastases • The role of major amputation in the management of the sarcoma patient ¬ Head and Neck (General Aspects) • Detailed anatomy of the following: o Anatomic triangles of the neck o Nodal areas of the neck o Oral cavity • Basic anatomy of the following: o Oropharynx o Hypopharynx o Larynx o Nasopharynx o Paranasal sinuses o Craniofacial skeleton • Detailed embryology of the upper aerodigestive tract • Basic physiology of speech and deglutition • The epidemiology, pathology and natural history of the common congenital, inflammatory and neoplastic processes in the head and neck • The indications for and interpretation of laboratory investigations and imaging studies for head and neck lesions ¬ Tracheostomy • The indications for elective and emergent surgical access to the airway: o Tracheostomy o Cricothyroidotomy • The complications of tracheostomy and discuss their management as follows: o Operative o Early postoperative o Later postoperative • Tracheostomy care as follows: o Stomal care o Tracheostomy tubes and appliances o Tracheobronchial toilet o Extubation ¬ Head and Neck Trauma (see also Learning Objectives for General Surgery Residents on the Trauma and Acute Care (Gold) Service Surgery Rotation) • The assessment of penetrating injuries to the neck with reference to the arbitrary division into Zones I,II and III, including: o Mandatory versus selective surgical exploration o Imaging studies o Endoscopic assessment

Page 2.6.4 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

• The surgical exposure of the great vessels in the thoracic inlet and neck • The clinical manifestations and principles of management of the following injuries to neck structures: o Great vessels o Trachea and larynx o Pharynx and esophagus o Thyroid o Salivary gland o Major nerves o Skin and soft tissue ¬ Early Cancer of the Lip • The clinical presentation and pathology of pre-malignant and malignant lesions of the lip, including: o Actinic damage o Invasive squamous cell carcinoma • The principles of tumour diagnosis and staging • The principles of management of pre-malignant and malignant change of the lower lip, including: o Selection of treatment modality o Resection of the primary o Reconstruction techniques o Management of the neck ¬ Early Oral Cancer • The clinical presentation and pathology of pre-malignant and malignant change in the oral cavity, including: o Leucoplakia o Erythroplasia o Invasive squamous cell carcinoma • The principles of tumour diagnosis and staging, including: o Incisional/excisional biopsy o Imaging studies • The principles of management of pre-malignant lesions and squamous cell carcinoma of the oral cavity, including: o Selection of treatment modality o Surgical management of the primary/type and extent of mandibular resection o Reconstruction techniques o Use and extent of elective neck dissection ¬ Neck Mass • Detailed anatomy of the neck with respect to neck dissection: o Marginal mandibular nerve o Accessory nerve o Relations of the posterior belly of the digastric muscle o Relations of the anterior scalene • The embryology of the upper aerodigestive tract as it pertains to common congenital lesions: o Cystic hygroma o Branchial cleft cyst/sinus o Thyroglossal duct cyst • The patterns of metastasis from squamous cell carcinoma of the upper aerodigestive tract • The differential diagnosis of a mass in the neck based on the following: o Age of the patient o Anatomic triangles, including the paraphyringeal space o Anatomic structures

Page 2.6.5 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

• The principles of tumour diagnosis and staging as it applies to a solitary neck mass, including: o Fine needle aspiration biopsy o Open biopsy o Diagnostic imaging • The principles of management for squamous cell carcinoma metastatic to the neck, including indications for radical neck dissection and its modifications ¬ Thyroid • The anatomy and embryology of the following: o Thyroid gland o Parathyroid gland o Recurrent laryngeal nerve • The physiology of the thyroid gland and the application and interpretation of the following: o Direct and indirect measurements of thyroid function o Measurements of autoimmunity o Measurements of thyroid and pituitary responsiveness o Assessment of thyroid anatomy o Assessment of thyroid histology/cytology • The evaluation and principles of management of thyroid disease, including: o Hyperthyroidism o Thyroiditis o Goitre o Hypothyroidism • The pathology of thyroid neoplasms: o Well-differentiated thyroid cancer ƒ Papillary ƒ Follicular o Medullary carcinoma o Anaplastic carcinoma o Lymphoma o Metastatic carcinoma • The surgical management of thyroid disease, including: o Goitre with airway compromise o Hyperthyroidism o Thyroid neoplasms • The diagnosis and management of the complications of thyroid surgery, including: o Airway obstruction o Early and severe hypocalcemia o Permanent hypocalcemia o Recurrent laryngeal nerve palsy o Thyroid storm • Follow-up of patients with thyroid malignancy and use of adjunctive treatment when appropriate, including: o TSH suppression o Thyroglogulin o Diagnostic and therapeutic use of radioactive iodine ¬ Parathyroid • Embryology and anatomy of the parathyroid glands • The differential diagnosis for hypercalcemia • The biochemical abnormalities associated with hyperparathyroidism • The investigation of hypercalcemia • The treatment of hypercalcemia as follows: o Asymptomatic o Symptomatic o Hypercalcemic crisis

Page 2.6.6 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

• Interpretation and use of currently available localization studies • The indications for parathyroidectomy • The surgical management of the following: o Primary hyperparathyroidism o Secondary hyperparathyroidism o Parathyroid carcinoma • The management of the complications of parathyroid surgery, including: o Hypocalcemia o Persistent hypercalcemia o Recurrent laryngeal nerve injury • The approach to parathyroid re-exploration in contrast to the initial exploration ¬ Salivary Gland • Anatomy of the parotid space, upper neck and submandibular triangle • The differential diagnosis of a parotid mass and swelling • The unique pathology of the more common types of salivary gland neoplasms, including: o Pleomorphic adenoma o Warthin’s tumour o Mucoepidermoid carcinoma o Adenoid cystic carcinoma o Malignant mixed tumour o Acinic cell carcinoma • The principles of tumour diagnosis and staging, including: o Fine needle aspiration biopsy o Open biopsy o Diagnostic imaging • The principles of management of salivary gland neoplasms, including: o Extent of parotid resection o Management of the facial nerve/facial reanimation o Use and extent of neck dissection o Role of adjunctive treatment

Perform a complete and appropriate assessment of a patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address patient problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective management plan in collaboration with a patient and his/her family • Demonstrate effective, appropriate and timely application of preventive and therapeutic interventions relevant to the Surgical Oncology (Green) Service rotation • Ensure appropriate informed consent is obtained for therapies • Ensure patients receive appropriate end-of-life care

The junior resident will be able to: • Perform the above clinical skills • Complete the data gathering process • Correctly diagnose most surgical oncology problems • Formulate management strategies; will require corroboration or modification by more senior individual

Page 2.6.7 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

The senior/chief resident will be able to: • Perform the above clinical skills • Complete the data gathering process efficiently • Correctly diagnose all surgical oncology problems • Formulate management strategies completely, even for complex or difficult problems

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Surgical Oncology (Green) Service rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Surgical Oncology (Green) Service rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base of all operative procedures performed on the Surgical Oncology (Green) Service rotation

Having completed the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Operative Procedures Junior Senior/Chief Breast Fine needle aspiration biopsy S S Breast cyst aspiration S S True-cut core biopsy S S Excision biopsy for benign lesion S S Excision biopsy for suspected cancer under local anesthesia S S Excision biopsy for suspected cancer after needle localization S S Excision biopsy for suspected cancer in the manner of a lumpectomy S S Excision biopsy for suspected cancer for a central lesion S S Segmental mastectomy S S Sentinel lymph node biopsy A/S S Axillary dissection (levels I and II) A/S S Total mastectomy +/- axillary dissection A/S S Subcutaneous mastectomy A S Breast reconstruction with submuscular implant A A Breast reconstruction with myocutaneous rotation flap A A Breast reconstruction with myocutaneous free flap A A Breast reconstruction with subcutaneous free flap A A Breast reconstruction following previous subcutaneous mastectomy A A/S Melanoma Excision biopsy S S Incision biopsy (when jndicated) S S Wide excision of primary with: S S • Appropriate margins • Optimal excision line • Primary closure when appropriate • Reconstruction with split-thickness skin graft if needed

Page 2.6.8 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

Operative Procedures Junior Senior/Chief Sentinel lymph node biopsy A/S S Axillary dissection A/S S Inguinal dissection A/S S Ileo-inguinal node dissection A S Radical/modified radical neck dissection A A/S Lymphoma Lymph node biopsy/optimum specimen handling S S Tissue biopsy of lymphoma in an extranodal site S S Central venous catheter insertion for chemotherapy S S Surgery for lymphoma of the GI tract (gastric/ileocolonic): A/S S • Biopsy • Resection • Bypass Surgery for complications of the above A S Sarcoma Open biopsy for staging S S Resection of soft tissue sarcoma Major amputation for limb sarcoma A A/S Head and Neck (General Aspects) Head and neck exam with visualization of the nasopharynx and A/S S larynx by indirect mirror examination and/or fibreoptic nasendoscopy Direct laryngoscopy S S Flexible bronchoscopy A/S S Flexible esophagoscopy A/S S Tracheostomy Endotracheal intubation S S Tracheostomy S S Cricothyroidotomy S S Laryngectomy with creation of a mature tracheostoma A A Head and Neck Trauma Cricothyroidotomy S S Tracheostomy S S Flexible esophagoscopy A/S S Flexible bronchoscopy A/S S Surgical exposure for control of a major vascular injury in Zone II of A S the neck Early Cancer of the Lip Biopsy of pre-malignant/malignant S S lesion of the lower lip V-excision of a carcinoma S S Vermilionectomy A/S S Resection of advanced cancer of the lip with reconstruction A A/S Early Oral Cancer Biopsy of pre-malignant/malignant lesion S S Peroral excision of an early pre-malignant/malignant lesion A/S S Composite resection of an oral/oropharyngeal tumour A A/S Neck Mass Fine needle aspiration biopsy S S Sistrunk procedure for thyroglossal duct cyst A/S S Excision of cystic hygroma A/S S

Page 2.6.9 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

Operative Procedures Junior Senior/Chief Excision of branchial cleft cyst/sinus A/S S Excisional biopsy of cervical lymph node S S Radical neck dissection A A/S Thyroid Fine needle aspiration biopsy S S Exposure of recurrent laryngeal nerve A/S S Identification of normal parathyroid tissue A/S S Total thyroid lobectomy A/S S Subtotal thyroid lobectomy A/S S Modified radical neck dissection for thyroid cancer A A/S Parathyroid Parathyroid exploration, including: A A/S • Identification of recurrent laryngeal nerve • Identification of abnormal and normal parathyroid tissue • Preservation of vascularized remnant • Cryopreservation of parathyroid tissue • Autotransplantation of parathyroid tissue Re-exploration for persistent hypercalcemia A A Salivary Gland Fine needle aspiration biopsy of parotid/submandibular mass S S Parotidectomy with identification and exposure of facial nerve and its A/S S branches Surgery for advanced/recurrent parotid neoplasm A A

Seek appropriate consultation from other professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of other health professionals as needed for the multi-modality assessment and management of surgical oncology patients • Arrange appropriate follow-up care services for a patient and his/her family

¾ Communicator At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with the surgical oncology patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Gather information about a disease, but also about a patient’s beliefs, concerns, expectations and illness experience • Seek out and synthesize relevant information from a patient’s family, caregivers and other professionals

Page 2.6.10 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the surgical oncology patient and family, colleagues and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making

Convey effective oral and written information • Maintain clear, accurate and appropriate records of clinical encounters and operative procedures • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Surgical Oncology (Green) Service rotation • Effectively present verbal reports of clinical encounters and medical information at Surgical Oncology (Green) Service rounds and multi-disciplinary rounds

¾ Collaborator At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Work with others to assess, plan, provide and integrate care for the surgical oncology patients • Participate effectively in multi-disciplinary oncology meetings

¾ Manager At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing surgical oncology patients

Serve in administration and leadership roles • Function as team leader for the trainees on the Surgical Oncology (Green) Service • Plan on-call schedules/operating room assignments for the trainees

¾ Health Advocate At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Respond to Surgical Oncology patient health needs and issues • Identify the health needs of an individual patient • Identify opportunities for advocacy, health promotion and disease prevention (e.g. cancer screening programs)

Page 2.6.11 Learning Objectives (Mandatory) – General Surgery – Green Service: Surgical Oncology

¾ Scholar At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise retrieved evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective lecture or presentation while assigned to the Surgical Oncology (Green) Service • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Surgical Oncology (Green) Service rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.6.12 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

2.7: GENERAL SURGERY – ORANGE SERVICE: GENERAL & HEPATOBILIARY SURGERY

PREAMBLE The General and Hepatobiliary Surgery (Orange) Service emphasizes clinical assessment, diagnostic evaluation and management of patients with a variety of hepatic, biliary and pancreatic problems. The resident is exposed to other general surgical conditions as well. Orange Service provides the resident with the unique opportunity to experience continuity of patient care beginning in the ambulatory surgical clinic, continuing in the operating room and culminating in hospital discharge and early follow-up.

GENERAL OBJECTIVES Upon completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident is expected to acquire the Knowledge (cognitive), clinical and technical skills (psychomotor) and attitudes (affective) essential to the CanMEDS roles/competencies pertinent to the General and Hepatobiliary Surgery Service rotation, including gender-related and ethnic perspectives. The resident is advised to review the Learning Objectives for General Surgery Residents on General Surgery Rotations in conjunction with these rotation-specific learning objectives. The junior resident should strive to become competent as a team leader in the day-to-day perioperative management of patients on the Service. The senior/chief resident should aim to demonstrate complete competence as a consultant in General Surgery, including authoritative team leadership and the provision of thoughtful, appropriate and complete management of general and (most) hepatobiliary surgical cases. Furthermore, he/she is charged with contributing to the education of more junior trainees by initiating discussions around appropriate clinical cases on a regular basis.

SPECIFIC OBJECTIVES At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will have acquired thefollowing competencies and will function as:

¾ Medical Expert At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the General and Hepatobiliary Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the General and Hepatobiliary Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Medical problems in the surgical patient, including: o Preoperative assessment o Preparation for specific operative interventions o Antimicrobial prophylaxis o Anticoagulation/thromboembolic prophylaxis o Corticosteroid management o Diabetes management

Page 2.7.1 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

• Conduct of a surgical procedure, including: o General principles o Specific operative interventions • Postoperative care, including: o Prevention and treatment of postoperative infections o Management of cardiac/hypertensive complications o Management of pulmonary complications o Management of thromboembolic complications o Management of endocrine/metabolic problems (e.g. diabetes) o Management of fluid and electrolyte/renal problems • Wound management and healing • Sepsis and surgical infections • Hemostasis and use of blood products • Fluid management and acid-base problems • Metabolic and nutritional care ¬ Liver • Liver anatomy, including: o Lobar/segmental anatomy o Vascular anatomy o Microscopic anatomy, including: ƒ Functional unit ƒ Hepatocyte • Hepatic physiology, including: o Metabolism, including: ƒ Carbohydrate metabolism ƒ Lipid metabolism ƒ Protein metabolism ƒ Bilirubin metabolism ƒ Vitamin metabolism ƒ Drug/toxin metabolism o Bile formation/secretion o Coagulation o Reticuloendothelial system • Assessment of liver function • Liver imaging, including: o Ultrasound o CT o MRI • Interventional diagnostic radiology, including: o Needle biopsy o Angiography o CT arterial portography • Presentation, principles of assessment and diagnostic strategy in the patient presenting with a liver mass • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common liver disorders, including: o Infectious diseases, including: ƒ Pyogenic abscess ƒ Amebic abscess ƒ Hydatid cyst

Page 2.7.2 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

o Benign neoplasms, including: ƒ Liver cell adenoma ƒ Focal nodular hyperplasia ƒ Hemangioma ƒ Hamartoma ƒ Simple cyst/polycystic liver disease o Malignant neoplasms, including: ƒ Hepatocellular carcinoma ƒ Metastatic tumours, including: à Colorectal tumours à Neuroendocrine tumours à Non-colorectal, non-neuroendocrine tumours • Principles of liver resection, including: o Indications/contraindications o Technical aspects of the following: ƒ Wedge resection ƒ Right hepatectomy ƒ Left hepatectomy ƒ Extended right hepatectomy (right trisegmentectomy) ƒ Left lateral segmentectomy ƒ Extended left hepatectomy (left trisegmentectomy) o Perioperative patient care o Complications of the above procedures o Expected outcomes • Non-resectional therapeutic interventions, including: o Percutaneous abscess/cyst drainage o Ablation of hepatic neoplasms, including: ƒ Embolization ƒ Radiofrequency ablation (RFA) o Hepatic artery catheterization for chemotherapy • Surgical complications of cirrhosis and portal hypertension, including: o Anatomy, physiology and pathophysiology of portal hypertension o Evaluation of the patient with cirrhosis o Principles of assessment and management of variceal hemorrhage, including: ƒ Endoscopic management ƒ Balloon tamponade ƒ Pharmacotherapy ƒ Transjugular intrahepatic portosystemic Shunt (TIPS) ƒ Portosystemic shunts ƒ Liver transplantation ¬ Biliary Tract • Biliary tract anatomy, including: o Extrahepatic biliary tract o Common anomalies/variations o Vascular anatomy • Biliary tract physiology, including: o Bile ducts o Gallbladder o Bile composition and function o Biliary motility • Bacteriology of the biliary tract/antibiotic selection

Page 2.7.3 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

• Biliary tract imaging, including: o Ultrasound/endoscopic ultrasound o CT o MRI/MRCP o Biliary scintigraphy o ERCP o Percutaneous transhepatic cholangiography • Interventional therapeutic radiology/endoscopy, including: o Percutaneous biliary drainage/stenting/lithotripsy o ERCP therapeutic techniques • Obstructive jaundice, including: o Differential diagnosis o Diagnostic evaluation/strategy o Principles of management • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common non-emergent biliary tract disorders, including: o Calculous biliary disease, including: ƒ Gallstone pathogenesis ƒ Diagnosis of gallbladder disease ƒ Laparoscopic/open cholecystectomy, including: à Indications à Technical considerations à Complications à Outcomes ƒ Choledocholithiasis ƒ Laparoscopic/open common bile duct exploration, including: à Indications à Technical considerations à Complications à Outcomes o Polypoid lesions of the gallbladder o Bile duct injury, including: ƒ Classification ƒ Approach to diagnosis/management ƒ Surgical/technical considerations o Choledochal cyst, including: ƒ Classification ƒ Approach to diagnosis/management ƒ Surgical/technical considerations o Gallbladder cancer o Cholangiocarcinoma, including: ƒ Classification ƒ Staging ƒ Surgical/technical considerations ƒ Palliative management ¬ Pancreas • Pancreatic anatomy, including congenital anomalies • Pancreatic physiology, including: o Exocrine function o Endocrine function o Assessment of pancreatic exocrine/endocrine function

Page 2.7.4 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

• Pancreatic imaging, including: o Ultrasound/endoscopic ultrasound o CT o MRI/MRCP o Scintigraphy o Angiography/portal venous sampling o ERCP • Interventional therapeutic radiology/endoscopy, including: o Percutaneous cyst drainage o ERCP therapeutic techniques • Presentation, pathophysiology, principles of assessment, diagnostic strategy, specific management, complications of disease and intervention and expected outcomes of common non-emergent disorders of the pancreas, including: o Chronic pancreatitis, including: ƒ Approach to diagnosis/management ƒ Surgical/technical considerations ƒ Pain management strategies o Benign exocrine tumours o Pancreatic adenocarcinoma, including: ƒ Staging ƒ Pancreaticoduodenectomy, jncluding: à Indications/contraindications/resectability à Technical considerations ƒ Resectional surgery for tumours of the body/tail ƒ Palliative surgical management ƒ Chemoradiation therapy for palliation o Islet cell tumours, including: ƒ Insulinoma ƒ Gastrinoma/Zollinger-Ellison syndrome ƒ VIPoma (Verner-Morrison syndrome) ƒ Glucagonoma ƒ Somatostatinoma ƒ Multiple endocrine neoplasia (MEN)

With respect to the above outline of cognitive objectives: • The PGY-1 resident and the junior resident will be able to outline the initial management of the listed conditions • The senior/chief resident will be able to describe the the listed conditions beyond initial management, including operative procedures, perioperative considerations, complications, expected outcomes and follow-up

Perform a complete and appropriate assessment of the general/hepatobiliary surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Page 2.7.5 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the general/hepatobiliary surgical patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the General and Hepatobiliary Surgery (Orange) Service rotation • Ensure appropriate informed consent is obtained for therapies

The Pgy-1 resident and the junior resident will be able to: • Perform many of the above clinical skills • Initiate well thought-out and appropriate management strategies; will require corroboration or modification by a more senior individual

The senior/chief resident will be able to: • Perform the above clinical skills • Formulate management strategies completely

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the General and Hepatobiliary Surgery (Orange) Service rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the General and Hepatobiliary Surgery (Orange) Service rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base of all operative procedures performed on the General and Hepatobiliary Surgery (Orange) Service rotation

Having completed the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to demonstrate technical competence for the following procedures: (Designation is listed as to expectation of Surgeon (S) or Assistant (A) for each procedure and for each level of training)

Operative Procedures PGY-1 Junior Senior/Chief General Diagnostic and Therapeutic Procedures Venipuncture/venous cutdown S S S Central venous catheter insertion S S S Urinary catheter insertion S S S Nasogastric tube insertion S S S Endoscopic Procedures Esophagogastroduodenoscopy NA S S Colonoscopy NA S S Endoscopic polypectomy NA S S Percutaneous endoscopic gasstrostomy (PEG) A A/S S Gastroduodenal Procedures Open partial gastric resection with Billroth I/Billroth II/Roux- A A/S S en-y reconstruction Open total gastrectomy A A S Open gastroenterotomy A S S

Page 2.7.6 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

Operative Procedures PGY-1 Junior Senior/Chief Open surgical gastrostomy techniques A A/S S Small Intestinal Procedures Open enterostomy (end/loop/feeding) A S S Open small intestinal resection/anastomosis A S S Open enteranastomosis A S S Stricturoplasty for Crohn’s disease A A/S S Colon and Rectal Procedures Open colostomy (end/loop) A A/S S Colostomy closure A A/S S Open colonic resection/anastomosis (segmental/subtotal) A A/S S Anterior resection with total mesorectal excision (TME) A A/S S Abdominoperineal resection with total mesorectal excision A A/S S (TME) Takedown of Hartmann A A/S S Liver Procedures Open liver biopsy A S S Wedge excision of liver lesion A A/S S Left lateral segmentectomy A A/S S Left hepatic lobectomy A A A/S Left trisegmentectomy A A A/S Right hepatic lobectomy A A A/S Right trisegmentectomy A A A/S Open radiofrequency ablation of liver lesion A A A/S Open decompression/management of liver abscess/cyst A A S Gallbladder and Biliary Tract Procedures Laparoscopic cholecystectomy and cholangiography A S S Open cholecystectomy and choangiography A S S Open cholecystostomy A S S Open common bile duct exploration A A S Biliary-intestinal anastomosis for tumour/stricture/bile duct A A S injury Operative management of choledochal cyst/neoplasm A A A/S Pancreatic Procedures Open drainage of pancreatic pseudocyst by anastomosis to A A/S S stomach or intestine Puestow procedure A A S Local excision of pancreatic lesion A A S Distal pancreatectomy A A/S S Pancreaticoduodenectomy (Whipple procedure) A A A/S Hernia and Abdominal Wall Procedures Elective open repair of inguinal hernia using tension-free A S S mesh technique Elective open repair of femoral hernia using tension-free A S S mesh technique Open repair of ventral (incisional) hernia A S S Repair of parastomal hernia A A/S S

Page 2.7.7 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

Seek appropriate consultation from other professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal patient care • Arrange appropriate follow-up care services for a patient and his/her family

¾ Communicator At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the general and hepatobiliary surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the General and Hepatobiliary Surgery (Orange) Service rotation • Effectively present verbal reports of clinical encounters and medical information during the General and Hepatobiliary Surgery (Orange) Service rotation

¾ Collaborator At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competence of other professionals in the management of the general/hepatobiliary surgical patient • Work with others to assess, plan, provide and integrate care of the general/hepatobiliary surgical patient • Demonstrate leadership on the General and Hepatobiliary Surgery (Orange) service

Page 2.7.8 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

¾ Manager At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing general/hepatobiliary surgical patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Respond to the needs of the general/hepatobiliary surgical patient • Identify health needs of an individual patient • Identify opportunities for advocacy, health promotion and disease prevention (e.g. promotion of healthy lifestyle for the prevention of liver/pancreatic disease)

¾ Scholar At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the general/hepatobiliary surgery evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the General and Hepatobiliary Surgery (Orange) Service • Provide effective feedback to faculty, residents and students

Page 2.7.9 Learning Objectives (Mandatory) – General Surgery – Orange Service: Hepatobiliary

¾ Professional At the completion of the General and Hepatobiliary Surgery (Orange) Service rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Manage appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.7.10 Learning Objectives (Mandatory) – Anatomy

2.8: ANATOMY

PREAMBLE Anatomy is basic to General Surgery. The Anatomy rotation allows the General Surgery resident the opportunity to review in-depth the areas of anatomy relevant to the practice of General Surgery. The Anatomy rotation includes a four week program of cadaver dissection at the Anatomy Laboratory located in the Department of Anatomy (Basic Medical Sciences Building). The resident must report to the main office in the Department of Anatomy on the first day of the rotation for instructions and cadaver assignment.

GENERAL OBJECTIVES Upon completion of the Anatomy rotation, the General Surgery resident is expected to: • Demonstrate knowledge in anatomy pertinent to General Surgery • Demonstrate knowledge of developmental anatomy pertinent to General Surgery • Develop tissue-handling/dissecting skills • Appreciate and respect the contribution of the deceased to the education of the living

SPECIFIC OBJECTIVES At the completion of the Anatomy rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Anatomy rotation, the General Surgery resident will be able to:

Establish and maintain knowledge, skills and attitudes appropriate to the Anatomy rotation • Apply knowledge of the fundamental biomedical sciences relevant to the Anatomy rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Neck Anatomy • Embryogenesis • Topographic anatomy, including: o Triangles of the neck • Vascular supply • Lymphatics/lymph nodes • Nerves • Specific Organs, including: o Thyroid gland o Parathyroid glands o Parotid gland o Trachea in the neck

Page 2.8.1 Learning Objectives (Mandatory) – Anatomy

¬ Thoracic Anatomy • Embryogenesis • Thoracic wall • Pleurae • Pulmonary anatomy • Mediastinum, including: o Anatomic subdivisions/contents, including: ƒ Thymus ƒ Esophagus ƒ Thoracic duct ƒ Nerves ƒ Lymphatics/lymph nodes ƒ Pericardium/heart/great vessels ¬ Breast and Axilla • Embryogenesis • Breast anatomy • Axillary anatomy, including: o Vascular anatomy o Lymphatics/lymph node levels o Brachial plexus and individual nerves ¬ Diaphragm • Embryogenesis • Central tendon • Esophageal hiatus/abdominal esophagus ¬ Abdominal Anatomy • Embryogenesis • Abdominal wall and groin, including: o Inguinofemoral area o Posterior (lumbar) abdominal wall • Peritoneum and omentum • Retroperitoneum, including: o Compartments of the retroperitoneal space o Communication of the retroperitoneal spaces o Abdominal aorta and its branches o Inferior vena cava and its branches o Nerves o Lymphatics/lymph nodes • Great vessels in the abdomen • Abdominal organs, including: o Stomach o Small intestine o Appendix o Large intestine and anorectum o Liver o Extrahepatic biliary tract and gallbladder o Pancreas o Spleen o Kidneys and ureters (general knowledge) o Adrenal glands (general knowledge) o Urinary bladder (general knowledge) o Male genital system (general knowledge) o Female genital system (general knowledge)

Page 2.8.2 Learning Objectives (Mandatory) – Anatomy

¬ Pelvis and Perineum • Pelvic sidewall, including: o Soft tissues o Vascular anatomy o Nerves • Pelvic floor • Perineum, including: o Boundaries o Subdivisions o Anal triangle ¬ Upper Extremity • Blood vessels of the antecubital fossa

Demonstrate proficient use of procedural skills Having completed the Anatomy rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Unilateral in-depth neck dissection in the cadaver • In-depth dissection of the thorax in the cadaver • In-depth dissection of the abdomen and pelvis in the cadaver • Unilateral in-depth dissection of the groin in the cadaver • In-depth dissection of the perineum in the cadaver • Superficial dissection of the blood vessels of the antecubital fossa in the cadaver • Unilateral in-depth dissection of the axilla in the cadaver

The General Surgery resident must follow the dissection manual and the dissection timetable available from the Surgical Education Office to complete the above technical objectives efficiently

¬ Educational Strategies The General Surgery resident will achieve the above objectives by means of the following: • Self-directed learning using facilities for dissection and self-study aids such as audiovisual presentations, plastic models, prosected materials and selected readings from anatomy textbooks and the dissection manual available from the Surgical Education Office ¬ Evaluation Strategies The General Surgery resident will be assessed with respect to the above objectives by means of the following: • Formal oral examinations in anatomy administered by Anatomy faculty • In-training evaluation by Anatomy faculty

¾ Scholar At the completion of the Anatomy rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Integrate new learning into development as a general surgeon

¾ Professional At the completion of the Anatomy rotation, the General Surgery resident will be able to:

Demonstrate an understanding of the contribution of the deceased to the education of the living • Exhibit appropriate professional behaviours, including compassion, and respect for the dignity of the deceased

Page 2.8.3 Learning Objectives (Mandatory) – Critical Care

2.9: CRITICAL CARE

PREAMBLE General surgeons are often involved in the care of patients who may be critically ill or injured and who may require management in the intensive care unit. Therefore the Critical Care rotation provides an excellent opportunity for the General Surgery resident to attain the knowledge and skills necessary for the management of the critically ill surgical patient.

GENERAL OBJECTIVES Upon completion of the Critical Care rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of critically ill patients • Demonstrate awareness of the ethical principles pertinent to critically ill patients, including end-of- life care and issues around withdrawing and withholding life support

SPECIFIC OBJECTIVES At the completion of the Critical Care rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Establish and maintain knowledge, skills and attitudes appropriate to the Critical Care rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Critical Care rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Airway Management • Principles of airway management • Indications for intubation ¬ Respiratory Critical Care • Interpretation of blood gases • Assessment of acid-base status • Provision of ventilator orders for most patients • ARDS ¬ Cardiac Critical Care • ACLS principles • Recognition of common rhythm disturbances • Interpretation of electrocardiogram/recognition of important life-threatening findings

Page 2.9.1 Learning Objectives (Mandatory) – Critical Care

¬ Shock • Classification of shock, including: o Hypovolemic shock o Distributive shock o Cardiogenic shock o Anaphylactic shock o Neurogenic shock • Outline of hemodynamic patterns specific to different causes of shock • Appropriate use of inotropes and vasopressors ¬ Sepsis and Critical Care • Organ failure associated with sepsis ¬ Renal Problems and Critical Care • Renal failure and principles of dialysis/ultrafiltration • Fluid and electrolyte disorders • Myoglobinuria ¬ Nutritional Support in Critical Care • Nutritional assessment in the ICU • Enteral nutrition • Parenteral nutrition ¬ Gastrointestinal and Hepatic Critical Care • Stress gastritis • Gastrointestinal bleeding • Hepatic failure

Perform a complete and appropriate assessment of the critically ill patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Examine and review each of the assigned patients before morning rounds • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate problem lists and to outline management plans

Use therapeutic interventions effectively • Implement an effective and prioritized management plan for the critically ill patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Critical Care rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Critical Care rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Critical Care rotation • Ensure appropriate informed consent is obtained for procedures • Compile and maintain an accurate and complete electronic data base of all procedures performed during the Critical Care rotation

Page 2.9.2 Learning Objectives (Mandatory) – Critical Care

Having completed the Critical Care rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Arterial line placement • Basic airway management, including: o Bag/mask ventilation o Uncomplicated intubation • Central venous catheter insertion • Application of ACLS principles in patient resuscitation

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the critically ill patient

¾ Communicator At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner, including: o Informed consent o Medical condition of the patient o Treatment plan o Prognosis o Primary and secondary prevention o Adverse events o Medical uncertainty o Medical errors o End-of-life wishes o Autopsy o Organ donation • Keep attending physicians appraised of relevant events

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters with each assigned patient on a daily basis • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Critical Care rotation • Effectively present verbal reports of clinical encounters and medical information in an organized and concise manner during the Critical Care rotation

Page 2.9.3 Learning Objectives (Mandatory) – Critical Care

¾ Collaborator At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the critically ill patient • Work with nursing colleagues and others to assess, plan, provide and integrate care of the critically ill patient

¾ Manager At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Respond to the needs of the critically ill patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the critical care evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Page 2.9.4 Learning Objectives (Mandatory) – Critical Care

¾ Professional At the completion of the Critical Care rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Recognize and appropriately respond to ethical issues such as consent, advanced directives, confidentiality, end-of-life care and withdrawing and withholding life support • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Page 2.9.5 Learning Objectives (Mandatory) – Emergency

2.10: EMERGENCY

GENERAL OBJECTIVES Upon completion of the Emergency rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of various emergency conditions • Develop a systemic approach to the assessment and treatment of the acutely ill/injured patient • Develop appropriate triage skills

SPECIFIC OBJECTIVES At the completion of the Emergency rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Emergency rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Emergency rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Emergency rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Cardiovascular Emergencies • Cardiac arrest • Arrhythmias • Pulmonary edema • Myocardial infarction • Hypertensive crisis • Cardiogenic shock • Vascular emergencies, including: o Ruptured abdominal aortic aneurysm o Acute arterial occlusion with ischemia o Vascular trauma o Acute venous problems • Cardiac tamponade • Myocardial injury/myocarditis ¬ Respiratory Emergencies • Airway problems/management • Asthma/bronchospasm/status asthmaticus • Pulmonary embolism • Respiratory failure • Pneumonia • Pleural effusion • Pneumothorax/hemothorax ¬ Neurologic Emergencies • Coma • Seizure disorders • Increased intracranial pressure and its manifestations

Page 2.10.1 Learning Objectives (Mandatory) – Emergency

¬ Gastrointestinal Emergencies • Acute abdomen • Gastrointestinal bleeding • Acute enteritis/colitis • Hepatobiliary emergencies, including: o Acute jaundice o Acute hepatitis o Cholangitis o Fulminant hepatic failure ¬ Endocrine Emergencies • Diabetic emergencies, including: o Hyperosmolar coma o Ketoacidosis • Hypoglycemia • Adrenal crisis • Hypercalcemia/hypocalcemia ¬ Trauma/Thermal Injuries • Initial assessment/management of the trauma patient • Acute wound care • Hypothermia • Hyperthermia syndromes • Burns ¬ Allergies/Anaphylaxis • Initial assessment/management ¬ Sepsis/septic shock • Initial assessment/management ¬ Psychiatric Emergencies • Delerium • Overdose • Acute situational reaction • Acute depression ¬ Pre-Hospital Care • Principles of triage • Disaster planning

Perform a complete and appropriate assessment of the patient with an emergency condition • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address emergency problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use therapeutic interventions effectively • Implement an effective and prioritized management plan for the emergency patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Emergency rotation • Ensure appropriate informed consent is obtained for therapies

Page 2.10.2 Learning Objectives (Mandatory) – Emergency

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Emergency rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Emergency rotation • Ensure appropriate informed consent is obtained for procedures • Compile and maintain an accurate and complete electronic data base of all procedures performed during the Emergency rotation

Having completed the Emergency rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Arterial puncture • Venipuncture • Venous cutdown • Central venous catheter insertion • Endotrachial intubation • Urinary catheter insertion • Nasogastric/orogastric tube insertion • Suture of laceration/initial wound care techniques • Paracentesis/peritoneal lavage • Lumbar puncture • Fracture stabilization techniques • Thoracentesis • Chest tube insertion • FAST (optional)

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the emergency patient

¾ Communicator At the completion of the Emergency rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Page 2.10.3 Learning Objectives (Mandatory) – Emergency

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures involving the emergency patients • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Emergency rotation • Effectively present verbal reports of clinical encounters and medical information during the Emergency rotation

¾ Collaborator At the completion of the Emergency rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the emergency patient • Work with others to assess, plan, provide and integrate care of the emergency patient

¾ Manager At the completion of the Emergency rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing emergency patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Emergency rotation, the General Surgery resident will be able to:

Respond to the needs of the emergency patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Emergency rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the emergency/acute care evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Page 2.10.4 Learning Objectives (Mandatory) – Emergency

¾ Professional At the completion of the Emergency rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Recognize and appropriately respond to ethical issues • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Page 2.10.5 Learning Objectives (Mandatory) – Endoscopy

2.11: ENDOSCOPY

PREAMBLE General surgeons perform diagnostic and therapeutic endoscopic procedures in their surgical practices. These procedures are very helpful in screening, surveillance and preoperative planning. The Endoscopy rotation provides the General Surgery resident a solid basis for further endoscopic experience on other rotations and for further training in more advanced endoscopic procedures after completion of training in General Surgery.

GENERAL OBJECTIVES Upon completion of the Endoscopy rotation, the General Surgery resident is expected to: • Demonstrate knowledge, technical skills and decision-making capabilities pertinent to the management of patients requiring routine upper and lower gastrointestinal endoscopy • Understand the functioning of a gastrointestinal endoscopy unit

SPECIFIC OBJECTIVES At the completion of the Endoscopy rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Endoscopy rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Endoscopy rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the upper and lower GI tract, including: o Normal anatomy o Alteration with surgery • Gastrointestinal Pathology • The gastrointestinal endoscopy unit, including: o Organization o Functions o Personnel • Principles of endoscopy, including: o Endoscopy basics o Endoscopy equipment, including: ƒ Instrument technology ƒ Accessories ƒ Cleaning and disinfection o Indications o Contraindications o Diagnostic techniques o Therapeutic techniques o Complications • Principles of conscious sedation

Page 2.11.1 Learning Objectives (Mandatory) – Endoscopy

¬ Specific Disease Entities • Upper GI Problems requiring endoscopy, including: o Esophageal problems, including: ƒ Gastroesophageal reflux disease, including: à Hiatus hernia à Schatzki’s ring à Esophagitis à Barrett’s esophagus à Strictures ƒ Esophageal cancer ƒ Esophageal varices ƒ Ingested foreign body o Gastric problems, including: ƒ Peptic ulceration ƒ Gastric erosions ƒ Gastritis ƒ Arteriovenous malformations ƒ Watermellon stomach ƒ Dieulafoy’s lesion ƒ Gastric cancer ƒ Gastric lymphoma/MALT lesions ƒ Bezoars ƒ H pylori, including: à Diagnosis à Treatment options ƒ Gastric varices ƒ Pyloric ulcer ƒ Pyloric stenosis/stricture o Duodenal problems, including: ƒ Duodenal ulcer ƒ Duodenitis ƒ Arteriovenous malformations of the duodenum ƒ Celiac disease o Other problems, including: ƒ Hemobilia ƒ Aortoenteric fistula ƒ Endoscopy for upper GI bleeding • Lower GI problems requiring endoscopy, including: o Anorectal disorders, including: ƒ Anal fissure ƒ Anal carcinoma ƒ Hemorrhoids ƒ Inflammatory bowel disease ƒ Solitary rectal ulcer ƒ Rectal cancer o Colonic disorders, including: ƒ Colitis, including: à Infectious colitis à Inflammatory bowel disease à Ischemic colitis ƒ Diverticular disease ƒ Polyps ƒ Colon cancer ƒ IBS/motility disorders ƒ Volvulus

Page 2.11.2 Learning Objectives (Mandatory) – Endoscopy

o Ileal disorders, including: ƒ Ileitis, including: à Crohn’s disease à Infectious ileitis ƒ Neoplasms, including: à Carcinoid tumour o Other problems, including: ƒ Endoscopy for lower GI bleeding

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Endoscopy rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Endoscopy rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Endoscopy rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all procedures performed on the Endoscopy rotation

Having completed the Endoscopy rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Diagnostic upper gastrointestinal endoscopy/biopsy • Diagnostic colonoscopy/biopsy • Most colonoscopic polypectomies • Flexible sigmoidoscopy • Rigid sigmoidoscopy • Hemorrhoid banding and ligation

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient • Arrange appropriate follow-up care services for the patient

Page 2.11.3 Learning Objectives (Mandatory) – Endoscopy

¾ Communicator At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Endoscopy rotation • Effectively present verbal reports of clinical encounters and medical information during the Endoscopy rotation

¾ Collaborator At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient undergoing endoscopy • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

Page 2.11.4 Learning Objectives (Mandatory) – Endoscopy

¾ Health Advocate At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Provide effective feedback to faculty

¾ Professional At the completion of the Endoscopy rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.11.5 Learning Objectives (Mandatory) – Internal Medicine

2.12: INTERNAL MEDICINE

PREAMBLE Medical conditions are common in surgical patients. Therefore, it is important for the General Surgery resident to have adequate exposure to Internal Medicine.

GENERAL OBJECTIVES Upon completion of the Internal Medicine rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of patients with medical problems • Evaluate and manage common medical conditions in order to provide appropriate perioperative care to surgical patients who happen to have medical co-morbidities

SPECIFIC OBJECTIVES At the completion of the Internal Medicine rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Internal Medicine rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Internal Medicine rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Cardiovascular Medicine • Cardiac evaluation • Cardiac pharmacology • Specific problems, including: o Chest pain and dyspnea o Hypertension o Coronary artery disease o Congestive heart failure o Valvular heart disease/endocarditis prophylaxis o Arrhythmias/conduction defects ¬ Respiratory Medicine • Pulmonary evaluation • Pulmonary pharmacology • Specific problems, including: o Chest pain and dyspnea o Asthma o Chronic obstructive pulmonary disease o Obstructive sleep apnea o Pneumonia/pulmonary infiltrates/atelectasis o DVT/pulmonary embolism/DVT prophylaxis o Pulmonary nodules o Pleural diseases

Page 2.12.1 Learning Objectives (Mandatory) – Internal Medicine

¬ Endocrinology • Diabetes mellitus o Diabetic medications o Management of glucose levels o Specific problems, including: ƒ Diabetic ketoacidosis ƒ Hyperosmolar coma • Thyroid disease, including: o Hypothyroidism o Hyperthyroidism • Adrenal insufficiency, including: o Assessment of glucocorticoid therapy and surgical stress • Pheochromocytoma ¬ Hematology/Oncology • Anemia and bleeding • Transfusion medicine • Coagulation disorders • Medical management of the oncology patient • Pain management ¬ Nephrology • Renal assessment • Pharmacology and renal disease • Specific problems, including: o Chronic kidney disease o Fluid and electrolyte disorders o Acid-base disorders o Renal failure ¬ GI Medicine/Hepatology • Gastrointestinal assessment • Hepatic assessment • Nutritional assessment • Parenteral/enteral nutritional therapy • GI pharmacology • Specific problems, including: o Liver disease, including: ƒ Acute hepatitis ƒ Cirrhosis/portal hypertension ƒ Jaundice o Gastrointestinal bleeding o Acid peptic disorders, including: ƒ GERD ƒ Peptic ulcer/H pylori ƒ Stress gastritis o Inflammatory bowel disease o Diarrhea o Malabsorption syndromes

Page 2.12.2 Learning Objectives (Mandatory) – Internal Medicine

¬ Infectious Diseases • Rational use of antimicrobials for treatment and prophylaxis • Specific problems, including: o Community acquired infections o Hospital acquired infections o Pneumonia o Endocarditis o Urosepsis o Meningitis o Osteomyelitis o Cellulitis o Overwhelming soft tissue infections, including: ƒ Necrotizing fasciitis ƒ Myonecrosis ƒ Fournier’ gangrene o Antibiotic-associated infections, including: ƒ Pseudomembranous colitis o The neutropenic patient o Pyrexia of unknown origin o HIV/AIDS o VRE/MRSA ¬ Neurology • Cerebrovascular disease • Seizures • Delerium • Parkinson’s disease • Myesthenia gravis • Multiple sclerosis ¬ Rheumatology • Systemic autoimmune disease, including: o Inflammatory arthritis o Spondylitis • Crystalline arthritis • Myositis • Systemic lupus erythematosis • Scleroderma • Antiphospholipid antibody syndrome • Osteoarthritis • Osteoporosis ¬ Alcohol Disorders • Alcohol withdrawal syndrome

Perform a complete and appropriate assessment of the Internal Medicine patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address medical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Page 2.12.3 Learning Objectives (Mandatory) – Internal Medicine

Use therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Internal Medicine rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Internal Medicine rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Internal Medicine rotation • Ensure appropriate informed consent is obtained for procedures • Compile and maintain an accurate and complete electronic data base of all procedures performed during the Internal Medicine rotation

Having completed the Internal Medicine rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Arterial puncture • Venipuncture • Venous cutdown • Central venous catheter insertion • Urinary catheter insertion • Nasogastric/orogastric tube insertion • Lumbar puncture • Thoracentesis • Paracentesis • Bone marrow aspiration

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient

¾ Communicator At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Page 2.12.4 Learning Objectives (Mandatory) – Internal Medicine

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Internal Medicine rotation • Effectively present verbal reports of clinical encounters and medical information during the Internal Medicine rotation

¾ Collaborator At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the medical evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Page 2.12.5 Learning Objectives (Mandatory) – Internal Medicine

¾ Professional At the completion of the Internal Medicine rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Recognize and appropriately respond to ethical issues such as consent, confidentiality and advanced directives • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Page 2.12.6 Learning Objectives (Mandatory) – Pediatric Surgery

2.13: PEDIATRIC SURGERY

PREAMBLE The rotation in Pediatric Surgery enables the General Surgery resident to appreciate the special needs of infants and children as surgical patients. Many of the surgical disorders encountered in children are similar in their presentation, management and outcome as in adults. The fundamental principles of surgical care are the same as those that govern surgical practice in older age groups. Additional issues that must be considered in dealing with pediatric surgical patients include: • The importance of understanding natural history of disease in this age group • The recognition that many pediatric surgical problems are more appropriately managed where there are special pediatric facilities providing expertise in anesthesia, critical care, diagnostic imaging, laboratory services and nursing care • Appreciation of the unique emotional and ethical issues surrounding care of the ill child

GENERAL OBJECTIVES Upon completion of the Pediatric Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical skills and decision-making capabilities pertinent to the management of many pediatric surgical problems • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of those pediatric surgical conditions encountered in a general surgical practice in a community lacking the immediate availability of a pediatric surgeon

SPECIFIC OBJECTIVES At the completion of the Pediatric Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Pediatric Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Pediatric Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows: • Understand the principles of neonatology, including: o Physiology of the premature infant, including: ƒ Fluid requirements ƒ Thermal neutrality ƒ Response to cold ƒ Metabolic rate ƒ Hepatic immaturity ƒ Renal function ƒ Nutritional management o Hyperbilirubinemia in the neonate o Intracranial bleeding in the neonate o Newborn respiratory distress syndrome

Page 2.13.1 Learning Objectives (Mandatory) – Pediatric Surgery

o Neonatal sepsis, including: ƒ Immune status ƒ Diagnostic workup ƒ Microbiology ƒ Pharmacokinetics • Understand the principles of pediatric critical care, including: o Fluids and electrolyte management o Acid-base equilibrium o Shock o Pulmonary physiology o Nutrition in pediatric critical care o Anesthesia for the pediatric patient o ECMO • Understand the logical approach to the following common symptom presentations: o Bilious vomiting o Non-bilious vomiting o Acute abdominal pain o Chronic abdominal pain o Constipation o Rectal bleeding • Demonstrate a thorough knowledge of the conditions that he/she should be able to manage as a general surgeon, including: o Head and neck lesions, including: ƒ Acute/chronic lymphadenitis ƒ Thyroglossal duct cyst ƒ Dermoid cyst ƒ Congenital torticolis ƒ Branchial cleft cyst/sinus ƒ Lymphangioma/hemolymphangioma ƒ Tongue tie ƒ Skin and subcutaneous lesions, including: à Nevi à Pilomatrixoma à Juvenile melanoma à Lipoma à Ingrown toenails à Paronychia à Pilonidal sinus disease o Abdominal problems, including: ƒ Umbilical hernia ƒ Umbilical granuloma ƒ Inguinal hernia ƒ Pyloric stenosis ƒ Intussusception ƒ Meckel’s diverticulum ƒ Acute appendicitis o Scrotal lesions, including: ƒ Hydrocele ƒ Undescended testicle ƒ Torsion of the appendix testes ƒ Epididymitis

Page 2.13.2 Learning Objectives (Mandatory) – Pediatric Surgery

• Understand the management of conditions that are ideally managed in a special pediatric facility and may demand initial management and occasionally definitive management locally because of urgency or distance, including: o Incarcerated inguinal hernia in the neonate o Aspirated/ingested foreign bodies/bezoars o Acute abdomen in the neonate, including: ƒ Necrotizing enterocolitis o Acute gastrointestinal bleeding o Pediatric trauma, including: ƒ Initial assessment/priorities ƒ Principles of operative and non-operative management of the following: à CNS trauma à Neck trauma à Chest trauma à Abdominal/pelvic trauma à Genitourinary trauma à Extremity trauma à Thermal injuries • Demonstrate a fundamental knowledge of conditions and problems likely to be seen initially by a general surgeon, but ideally managed in a specialty pediatric facility, including: o Congenital lesions of the lung and mediastinum, including: ƒ Cystic adenomatoid malformation ƒ Pulmonary sequestration ƒ Lobar emphysema ƒ Blebs and spontaneous pneumothorax ƒ Hypoplasia ƒ Pulmonary hypertension ƒ Mediastinal cysts ƒ Mediastinal neoplasia o Diaphragmatic hernia o Surgical management of gastroesophageal reflux o Pectus excavatum/pectus carinatum o Solid neoplasms of childhood, including: ƒ Renal neoplasms, including: à Wilm’s tumour à Mesoblastic nephroma ƒ Adrenal neoplasms, including: à Neuroblastoma à Ganglioneuroblastoma à Carcinoma ƒ Liver neoplasms, including: à Hemangioma à Hamartoma à Adenoma à Focal nodular hyperplasia à Hepatoblastoma à Hepatoma

Page 2.13.3 Learning Objectives (Mandatory) – Pediatric Surgery

ƒ Soft tissue tumours, including: à Neurofibroma à Rhabdomyosarcoma à Fibrosarcoma à Liposarcoma à Leiomyosarcoma ƒ Teratomas ƒ Lymphomas ƒ Gonadal tumours, including: à Testicular à Ovarian • Understand the presentation, natural history, principles of management and outcome of conditions that should be treated exclusively in a specialized pediatric surgical facility, including: o Diaphragmatic hernia o Tracheoesophageal fistula o Gastroschisis o Omphalocele o Intestinal atresias o Biliary Conditions, including: ƒ Biliary atresia ƒ Biliary hypoplasia ƒ Choledochal cyst o Pancreatic conditions, including: ƒ Cystic fibrosis ƒ Pancreas divisum ƒ Annular pancreas ƒ Congenital cysts ƒ Neoplasia o Splenic conditions, including: ƒ Hereditary spherocytosis ƒ Thalassemia ƒ ITP ƒ Gaucher’s disease ƒ Splenic cyst ƒ Splenic abscess ƒ Overwhelming post-splenectomy infection o Hirschsprung’s disease o Imperforate anus o Intestinal malrotation o Major pulmonary parenchymal disease o Intersex anomalies, including ethical implications of gender assignment with respect to the following: ƒ Adrenogenital syndrome ƒ Mixed gonadal dysgenesis ƒ True and pseudo-hermaphroditism ƒ Testicular feminization syndrome and its variants

Page 2.13.4 Learning Objectives (Mandatory) – Pediatric Surgery

o Endocrine Conditions, including: ƒ Thyroid problems, including: à Hyperthyroidism à Thyroiditis à Neoplasia à Management of thyroid mass following irradiation ƒ Parathyroid conditions, including: à Hypoparathyroidism à Hyperparathyroidism ƒ Breast conditions, including: à Neonatal hypertrophy à Mastitis à Gynecomastia à Nipple discharge à Fibroadenoma à Phylloides tumours à Premature thelarche ƒ Functional pancreatic tumours ƒ Adrenal conditions ƒ Testicular conditions, including: à Cryptorchidism à Tumours

Perform a complete and appropriate assessment of the pediatric surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the pediatric surgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the pediatric surgical patient, including appropriate and expeditious patient disposition in the acute care setting • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Pediatric Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Pediatric Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Pediatric Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Pediatric Surgery rotation

Page 2.13.5 Learning Objectives (Mandatory) – Pediatric Surgery

Having completed the Pediatric Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • ATLS principles and procedures • Venous cutdown • Central venous catheter insertion • Portacath insertion • Tracheostomy • Incision/drainage of subcutaneous abscess • Excision of simple skin/subcutaneous lesion • Open appendectomy • Laparoscopic appendectomy • Reduction of intussusception • Reduction of incarcerated inguinal hernia • Repair of indirect inguinal hernia • Repair of hydrocele • Repair of umbilical hernia • Repair of epigastric hernia • Pyloromyotomy • Cervical lymph node biopsy • Gastrostomy • Colostomy • Bowel resection • Principles and techniques of the following endoscopic procedures: o Esophagogastroduodenoscopy o Proctosigmoidoscopy o Colonoscopy

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the pediatric surgical patient • Arrange appropriate follow-up care services for the pediatric surgical patient

¾ Communicator At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the pediatric surgical patient and family, colleagues and other professionals in a humane and understandable manner

Page 2.13.6 Learning Objectives (Mandatory) – Pediatric Surgery

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the pediatric surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Pediatric Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Pediatric Surgery rotation

¾ Collaborator At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals (e.g. nurses/ET nurses, nursing assistants, dieticians and physiotherapists) in the management of the pediatric surgical patient • Work with others to assess, plan, provide and integrate care of the pediatric surgical patient • Demonstrate leadership in the day-to-day running of resident/student team activities on the Pediatric Surgery rotation

¾ Manager At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing pediatric surgical patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings • Lead the Pediatric Surgery team effectively and efficiently

¾ Health Advocate At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the pediatric surgical patient • Identify the health needs of an individual patient • Identify opportunities for child health advocacy, health promotion and disease prevention (e.g. travel safety; helmet use)

¾ Scholar At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Page 2.13.7 Learning Objectives (Mandatory) – Pediatric Surgery

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Pediatric Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Pediatric Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.13.8 Learning Objectives (Mandatory) – Vascular Surgery

2.14: VASCULAR SURGERY

GENERAL OBJECTIVES Upon completion of the Vascular Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of patients with vascular disorders • Demonstrate vascular surgical technical skills pertinent to the practice of a general surgeon

SPECIFIC OBJECTIVES At the completion of the Vascular Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Vascular Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Vascular Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Vascular Anatomy • Arterial anatomy • Venous anatomy • Anatomy of the lymphatic system ¬ Vascular Assessment • Diagnostic imaging, including: o Angiography o CT angiography o Doppler and duplex ultrasound o Segmental pressure measurements ¬ Arterial Disorders • Peripheral arterial occlusive disease, including: o Atherosclerosis o Acute thromboembolic disease o Chronic occlusive disease o Peripheral aneurysms • Renovascular occlusive disease • Abdominal aortic aneurysms • Extracranial cerebrovascular disease • Vasospastic disorders • Principles of endovascular surgery ¬ Mesenteric Ischemia • Acute mesenteric arterial occlusion • Nonocclusive mesenteric insufficiency • Chronic mesenteric insufficiency • Mesenteric venous occlusion

Page 2.14.1 Learning Objectives (Mandatory) – Vascular Surgery

¬ Arteriovenous Fistula ¬ Venous Disease • Venous thromboembolic disorders, including: o Deep venous thrombosis, including: ƒ Prophylaxis ƒ Diagnosis and management o Chronic venous insufficiency • Portal hypertension ¬ Lymphatic Disorders • Lymphedema • Thoracic duct disorders • Chylothorax • Chyloperitoneum • Lymphatic neoplasia ¬ Compartment Syndromes ¬ Vascular Trauma ¬ Vascular access and Ports

Perform a complete and appropriate assessment of the vascular surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the vascular surgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the vascular surgical patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Vascular Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Vascular Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Vascular Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Vascular Surgery rotation

Having completed the Vascular Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Doppler vascular assessment • Central venous catheter insertion • Portacath insertion

Page 2.14.2 Learning Objectives (Mandatory) – Vascular Surgery

• Control of major hemorrhage/vascular control in the operating room, including: o Cross-clamping of the aorta o Proximal and distal control of blood vessels • Operative exposure of the aorta and its major branches • Operative exposure of the inferior vena cava • Repair of a traumatized artery • Patching of a diseased artery • Management of arterial emboli • Minor and major amputations of the lower extremity • Vascular anastomosis • Varicose vein treatment, including: o Ligation o Stripping o Sclerotherapy • Fasciotomy for compartment syndrome

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the vascular surgical patient • Arrange appropriate follow-up care services for the vascular surgical patient

¾ Communicator At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the vascular surgical patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the vascular surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Vascular Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Vascular Surgery rotation

Page 2.14.3 Learning Objectives (Mandatory) – Vascular Surgery

¾ Collaborator At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the vascular surgical patient • Work with others to assess, plan, provide and integrate care of the vascular surgical patient • Demonstrate leadership in the day-to-day running of resident/student team activities on the Vascular Surgery rotation

¾ Manager At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the vascular surgical patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Vascular Surgery rotation • Provide effective feedback to faculty, residents and students

Page 2.14.4 Learning Objectives (Mandatory) – Vascular Surgery

¾ Professional At the completion of the Vascular Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 2.14.5

Section 3: Learning Objectives

(Elective Rotations) Learning Objectives (Elective) – Anesthesiology

3.1: ANESTHESIOLOGY

PREAMBLE Contemporary general surgical practice has evolved in step with advances in preoperative assessment and perioperative management of patients with increasingly more complex medical conditions. The Anesthesiology elective allows the General Surgery resident the opportunity to gain insight into the importance of careful preoperative assessment and perioperative support of the surgical patient.

GENERAL OBJECTIVES Upon completion of the Anesthesiology rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to preoperative patient assessment and management • Develop a systemic approach to the assessment of the surgical patient with high anesthetic risk • Appreciate the collaborative anesthesiologist-surgeon relationship

SPECIFIC OBJECTIVES At the completion of the Anesthesiology rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Anesthesiology rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Anesthesiology rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy pertinent to Anesthesiology, including: o Airway o Neck anatomy for vascular access o Spinal anatomy • Physiology pertinent to Anesthesiology, including: o Cardiac o Respiratory o Acid-base equilibrium o Neurophysiology • Pharmacology pertinent to Anesthesiology, including: o Anesthetics, including: ƒ Inhalation agents ƒ Regional agents o Analgesic medications o Neuromuscular blocking agents o Inotropic drugs o Cardiac drugs o Respiratory drugs o Anti-emetic drugs • Principles of pain management

Page 3.1.1 Learning Objectives (Elective) – Anesthesiology

¬ Specific Entities • Preoperative assessment, including: o Anesthetic risk assessment and scoring o Airway assessment o Cardiovascular assessment o Respiratory assessment o Endocrine considerations, including: ƒ Thyroid disorders ƒ Diabetes ƒ Corticosteroid management ƒ Pheochromocytoma/blockade • Airway management • Methods of anesthesia, including: o General anesthesia o Spinal anesthesia o Epidural anesthesia o Regional anesthesia o Local anesthesia • Conscious sedation • Patient monitoring in anesthesia • Perioperative fluid and electrolyte management • Perioperative transfusion medicine • Perioperative respiratory management, including: o Monitoring o Ventilator management • Patient safety in the operating room • Principles of venous access

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Anesthesiology rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Anesthesiology rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Anesthesiology rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all procedures performed on the Anesthesiology rotation

Page 3.1.2 Learning Objectives (Elective) – Anesthesiology

Having completed the Anesthesiology rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Techniques used in airway establishment and maintenance • Central venous catheter insertion using internal jugular approach • Radial arterial catheter insertion • Local anesthetic techniques

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient

¾ Communicator At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the vascular surgical patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Anesthesiology rotation • Effectively present verbal reports of clinical encounters and medical information during the Anesthesiology rotation

¾ Collaborator At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

Page 3.1.3 Learning Objectives (Elective) – Anesthesiology

¾ Manager At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Provide effective feedback to faculty

¾ Professional At the completion of the Anesthesiology rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.1.4 Learning Objectives (Elective) – Cardiac Surgery

3.2: CARDIAC SURGERY

PREAMBLE This elective rotation is very useful for the General Surgery resident interested in trauma and critical care.

GENERAL OBJECTIVES Upon completion of the Cardiac Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities with respect to those aspects of Cardiac Surgery pertinent to trauma and critical care

SPECIFIC OBJECTIVES At the completion of the Cardiac Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Cardiac Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Cardiac Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Cardiopulmonary anatomy • Cardiopulmonary physiology • Pharmacology of cardiac drugs • Principles of cardiopulmonary bypass ¬ Specific Disease Entities • Congenital heart disease in the adult • Coronary artery disease • Acquired valvular heart disease • Arrhythmias/pacemakers • Diseases of the great vessels • Cardiac/great vessel trauma

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Page 3.2.1 Learning Objectives (Elective) – Cardiac Surgery

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Cardiac Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Cardiac Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Cardiac Surgery rotation • Ensure appropriate informed consent is obtained for operative procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Cardiac Surgery rotation

Having completed the Cardiac Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Surgical exposure of the mediastinum, including: o Median sternotomy o Thoracotomy • Management of cardiac tamponade • Saphenous vein harvesting • Exposure of cephalic vein for pacemaker electrode • Subclavian vein cannulation • Control of major hemorrhage/vascular control in the operating room, including: o Cross-clamping of the aorta o Proximal and distal control of blood vessels

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient

¾ Communicator At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Page 3.2.2 Learning Objectives (Elective) – Cardiac Surgery

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the cardiac surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Vascular Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Cardiac Surgery rotation

¾ Collaborator At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Page 3.2.3 Learning Objectives (Elective) – Cardiac Surgery

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Cardiac Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Cardiac Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.2.4 Learning Objectives (Elective) – Gastroenterology

3.3: GASTROENTEROLOGY

PREAMBLE Gastrointestinal disorders and their management are very common in general surgical practice and often involve the collaborative efforts of the gastroenterologist and the general surgeon. Furthermore, there is often overlap with respect to their roles in the management of the GI patient.

GENERAL OBJECTIVES Upon completion of the Gastroenterology rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of patients with gastrointestinal problems • Appreciate the important collaborative relationship between the gastroenterologist and the general surgeon

SPECIFIC OBJECTIVES At the completion of the Gastroenterology rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Gastroenterology rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Gastroenterology rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Normal gastrointestinal physiology • Normal hepatobiliary physiology • Normal pancreatic physiology • Microbiology of the GI tract, including: o H pylori o Colonic flora o C difficile • Gastrointestinal pathology • Pharmacology pertinent to the practice of GI Medicine, including: o Conscious sedation medications o H2 blockers o Proton pump inhibitors o Drugs for inflammatory bowel disease o Drugs for IBS o Prokinetic drugs • GI assessment, including: o Imaging o Endoscopy o GI function testing o Motility testing

Page 3.3.1 Learning Objectives (Elective) – Gastroenterology

• Nutrition • Gastrointestinal bleeding ¬ Specific Disease Entities • Esophagus, including: o Motility disorders, including: ƒ Achalasia ƒ Diffuse esophageal spasm ƒ Nutcracker esophagus o Gastroesophageal reflux disease, including: ƒ Esophagitis ƒ Schatzki’s ring ƒ Stricture ƒ Barrett’s esophagus o Cancer of the esophagus and gastroesophageal junction o Esophageal varices and portal hypertension o Caustic injury o Esophageal webs • Stomach and duodenum, including: o Peptic ulcer o Gastric erosions/gastritis o Gastric neoplasia, including: ƒ Gastric cancer ƒ Gastric lymphoma ƒ GIST o Post-gastrectomy problems o Arteriovenous malformations o Watermellon stomach o Dieulafoy’s lesion • Small intestine, including: o Enteritis/Crohn’s o Small intestinal neoplasia o Celiac disease o Mesenteric ischemia o Short bowel syndrome/intestinal failure • Colon and rectum, including: o Colitis, including: ƒ Inflammatory bowel disease ƒ Infectious colitis ƒ C difficile colitis ƒ Ischemic colitis o Motility disorders o Colorectal polyps and polyp syndromes o Colorectal cancer o Diverticular disease o Arteriovenous malformations • Liver and biliary tract, including: o Portal hypertension and cirrhosis o Hepatitis o Liver tumours o Liver cysts and abscesses o Gallstone disease o Sclerosing cholangitis

Page 3.3.2 Learning Objectives (Elective) – Gastroenterology

• Pancreas, including: o Pancreatitis, including: ƒ Acute pancreatitis ƒ Chronic pancreatitis o Pancreatic neoplasia, including: ƒ Endocrine tumours ƒ Exocrine tumours

Perform a complete and appropriate assessment of the Gastroenterology patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Recommend an effective and prioritized management plan for the patient

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Gastroenterology rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Gastroenterology rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Compile and maintain an accurate and complete electronic data base for all procedures performed on the Gastroenterology rotation

Having completed the Gastroenterology rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Paracentesis • Esophagogastoduodenoscopy (if the General Surgery resident has already completed the Endoscopy rotation) • Colonoscopy (if the General Surgery resident has already completed the Endoscopy rotation) • Flexible sigmoidoscopy (if the General Surgery resident has already completed the Endoscopy rotation)

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient

¾ Communicator At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Page 3.3.3 Learning Objectives (Elective) – Gastroenterology

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures involving the Gastroenterology patients • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Gastroenterology rotation • Effectively present verbal reports of clinical encounters and medical information during the Gastroenterology rotation

¾ Collaborator At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

Page 3.3.4 Learning Objectives (Elective) – Gastroenterology

¾ Scholar At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Gastroenterology rotation • Provide effective feedback to faculty

¾ Professional At the completion of the Gastroenterology rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.3.5 Learning Objectives (Elective) – Neurosurgery

3.4: NEUROSURGERY

PREAMBLE The Neurosurgery rotation is valuable for the General Surgery resident who is interested in a career in trauma and critical care.

GENERAL OBJECTIVES Upon completion of the Neurosurgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to patients with neurosurgical problems, including neurological trauma • Understand and appreciate the importance of the neurosurgeon as a member of the interdisciplinary trauma team

SPECIFIC OBJECTIVES At the completion of the neurosurgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Neurosurgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Neurosurgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Neuroanatomy, including: o CNS o Peripheral nervous system • Neurophysiology • Imaging in Neurosurgery, including: o CT o MRI o Angiography ¬ Specific Disease Entities • Neurological trauma, including: o CNS injuries o Spinal cord injuries o Peripheral nerve injuries o Management of increased intracranial pressure

Perform a complete and appropriate assessment of the Neurosurgery patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner

Page 3.4.1 Learning Objectives (Elective) – Neurosurgery

• Demonstrate effective clinical problem solving and judgment to address the neurosurgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the neurosurgical patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Neurosurgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Neurosurgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Neurosurgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Neurosurgery rotation

Having completed the Neurosurgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Intracranial pressure monitoring • Lumbar puncture • Spinal stabilization techniques • Burr holes (optional)

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the neurosurgical patient • Arrange appropriate follow-up care services for the neurosurgical patient

¾ Communicator At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the neurosurgical patient and family, colleagues and other professionals in a humane and understandable manner

Page 3.4.2 Learning Objectives (Elective) – Neurosurgery

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the neurosurgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Neurosurgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Neurosurgery rotation

¾ Collaborator At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the neurosurgical patient • Work with others to assess, plan, provide and integrate care of the neurosurgical patient

¾ Manager At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Respond to the needs of the Neurosurgical patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Page 3.4.3 Learning Objectives (Elective) – Neurosurgery

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Neurosurgery rotation • Provide effective feedback to faculty

¾ Professional At the completion of the Neurosurgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.4.4 Learning Objectives (Elective) – Orthopedic Surgery

3.5: ORTHOPEDIC SURGERY

PREAMBLE Skeletal injuries are commonly encountered in the multiple trauma setting. Furthermore, assessment and management of orthopedic problems is often an integral part of rural general surgical practice. Therefore, the General Surgery resident interested in a career it trauma care or rural practice will find the Orthopedic Surgery rotation very useful.

GENERAL OBJECTIVES Upon completion of the Orthopedic Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the management of some musculoskeletal disorders • Understand and appreciate the role of the orthopedic surgeon as a member of the interdisciplinary trauma team

SPECIFIC OBJECTIVES At the completion of the Orthopedic Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Orthopedic Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Orthopedic Surgery rotation

The resident in General Surgery is expected to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the axial and appendicular skeleton • Bone physiology • Musculoskeletal imaging, including: o Plain radiographs o CT o MRI • Principles of splinting and casting ¬ Specific Disease Entities • Musculoskeletal trauma, including: o Extremity fractures and dislocations o Spinal injuries o Pelvic fractures and associated injuries • Hand problems, including: o Injuries o Infections o Carpal tunnel syndrome o Ganglia • Osteomyelitis • Soft tissue neoplasia

Page 3.5.1 Learning Objectives (Elective) – Orthopedic Surgery

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the orthopedic problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Orthopedic Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Orthopedic Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Orthopedic Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Orthopedic Surgery rotation

Having completed the Orthopedic Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Application of casts • Splinting techniques • Closed reduction of simple fractures • Closed reduction of simple dislocations • Primary management of certain compound fractures (in the absence of an orthopedic specialist) • Lower extremity amputations • Carpal tunnel release • Excision of soft tissue neoplasms • Excision of ganglia

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient • Arrange appropriate follow-up care services for the patient

Page 3.5.2 Learning Objectives (Elective) – Orthopedic Surgery

¾ Communicator At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the orthopedic patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Orthopedic Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Orthopedic Surgery rotation

¾ Collaborator At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

Page 3.5.3 Learning Objectives (Elective) – Orthopedic Surgery

¾ Health Advocate At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Orthopedic Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Orthopedic Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.5.4 Learning Objectives (Elective) – Plastic Surgery

3.6: PLASTIC SURGERY

PREAMBLE The principles of complex wound and thermal injury management are an integral part of the Plastic Surgery rotation. This rotation is especially valuable for the resident interested in a career in trauma care or a rural general surgical practice.

GENERAL OBJECTIVES Upon completion of the Plastic Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities in the management of those plastic surgical problems pertinent to the general surgical specialist • Understand and appreciate the role of the plastic surgeon as a member of the interdisciplinary trauma team • Understand and appreciate the role of the plastic surgeon as a member of the interdisciplinary oncology team with respect to reconstructive surgery

SPECIFIC OBJECTIVES At the completion of the Plastic Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Plastic Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Plastic Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Principles of wound healing • Principles of wound management • Skin incisions and excisions • Open wounds • Wound closure • Debridement and irrigation • Grafts • Flaps, including: o Skin flaps o Myocutaneous flaps o Free flaps

Page 3.6.1 Learning Objectives (Elective) – Plastic Surgery

¬ Specific Disease Entities • Trauma, including: o Maxillofacial trauma o Soft tissue injuries,including: ƒ Abrasions ƒ Lacerations ƒ Blast injuries ƒ Human/animal bites o Hand injuries o Thermal injuries, including: ƒ Burns ƒ Frostbite and other cold injuries • Soft tissue infections, including: o Cellulites o Abscess o Necrotizing soft tissue infections, including: ƒ Myonecrosis ƒ Fasciitis ƒ Fournier’s gangrene • Reconstruction following surgery, including: o Breast reconstruction o Abdominal wall reconstruction o Head and neck reconstruction following oncology surgery o Reconstruction following surgery for melanoma • Pressure sores • Chronic ulcers, including: o Venous stasis ulcers o Ischemic ulcers o Diabetic ulcers • Carpal Tunnel Syndrome

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Plastic Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Plastic Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Plastic Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes

Page 3.6.2 Learning Objectives (Elective) – Plastic Surgery

• Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Plastic Surgery rotation

Having completed the Plastic Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Suturing of complex wounds • Skin grafting techniques • Skin flap techniques • Tendon repair techniques • Debridement and irrigation of wounds • Initial assessment, resuscitation and treatment of patients with major burns • Escharotomies for burn management • Surgical drainage of paronychia • Surgical drainage of felon • Carpal tunnel release

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient • Arrange appropriate follow-up care services for the patient

¾ Communicator At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Plastic Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Plastic Surgery rotation

Page 3.6.3 Learning Objectives (Elective) – Plastic Surgery

¾ Collaborator At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the plastic surgical patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Plastic Surgery rotation • Provide effective feedback to faculty, residents and students

Page 3.6.4 Learning Objectives (Elective) – Plastic Surgery

¾ Professional At the completion of the Plastic Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.6.5 Learning Objectives (Elective) – Radiology

3.7: RADIOLOGY

PREAMBLE Correct diagnosis and appropriate management of the surgical patient often depend on timely diagnostic imaging techniques. Therefore, the General Surgery resident must understand and appreciate the appropriate indications for and the merits of the available imaging procedures. Furthermore, he/she should be able to interpret the resultant images in order to facilitate appropriate and timely patient management.

GENERAL OBJECTIVES Upon completion of the Radiology rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities with respect to diagnostic imaging pertinent of the practice of General Surgery • Understand and appreciate the role of the radiologist as a member of an interprofessional healthcare team

SPECIFIC OBJECTIVES At the completion of the Radiology rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Radiology rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Radiology rotation • Apply knowledge of the clinical fundamental biomedical sciences relevant to the Radiology rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Radiation physics and radiobiology with respect to the following: o Conventional radiology o CT o MRI o Ultrasound o Diagnostic nuclear medicine (optional) • Principles of the above imaging techniques, including: o Areas of application o Indications o Contraindications o Limitations • Radiation hazards

Page 3.7.1 Learning Objectives (Elective) – Radiology

¬ Specific Applications • Conventional radiology, including: o Plain abdominal radiographs o Chest radiographs o Gastrointestinal contrast imaging o Biliary imaging, including: ƒ ERCP ƒ PTC o Mammography and needle localization techniques o Urologic imaging, including: ƒ IVP ƒ Cystography o Angiography o Venography • CT, including: o Head o Chest o Abdomen/pelvis o CT angiography • MRI, including: o Chest o Abdomen o Pelvis (rectal cancer assessment) o MRCP o Breast o Soft tissues • Ultrasound, including: o Upper abdomen o Pelvis o Breast o Transrectal ultrasound (rectal cancer assessment) o Doppler studies (vascular assessment) o Thyroid • Diagnostic nuclear medicine (optional), including: o Ventilation/perfusion scanning o Gastric emptying scanning o Tagged-RBC scanning o Bone scanning o Bone density studies o Gallium scanning o WBC scanning

Perform a complete and appropriate assessment of the patient • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment, including interpreting available data and integrating information to generate differential diagnoses and management plans

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Radiology rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed

Page 3.7.2 Learning Objectives (Elective) – Radiology

Having completed the Radiology rotation, the General Surgery resident will be able to demonstrate knowledge and competence in interpretation of the following: • Chest radiographs • Plain abdominal radiographs • Radiographs of the axial and appendicular skeleton • Gastrointestinal contrast imaging • Biliary imaging, including: o ERCP o PTC • Mammograms • CT, including: o Head o Chest o Abdomen/pelvis o CT angiograms o Spine • MRI, including: o Head o Abdomen o MRCP o Pelvis • Diagnostic ultrasound (optional)

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient

¾ Communicator At the completion of the Radiology rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and familieis • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of procedures performed during the Radiology rotation • Effectively present verbal reports of clinical encounters and medical information during the Radiology rotation

Page 3.7.3 Learning Objectives (Elective) – Radiology

¾ Collaborator At the completion of the Radiology rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Radiology rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Radiology rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Radiology rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

¾ Professional At the completion of the Radiology rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.7.4 Learning Objectives (Elective) – Surgical Infectious Diseases

3.8: SURGICAL INFECTIOUS DISEASES

PREAMBLE This rotation exposes the General Surgery resident to the important infectious diseases encountered by hospitalized surgical patients. An evidence-based approach is stressed by the faculty who provide one-on- one teaching to the resident.

GENERAL OBJECTIVES Upon completion of the Surgical Infectious Diseases rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the diagnosis and management of infections in surgical patients • Understand and practice the safe and appropriate usage of antimicrobials • Understand and apply the principles of infection control/safe practices • Understand and appreciate the role of the microbiology laboratory in the diagnosis and management of infections

SPECIFIC OBJECTIVES At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Surgical Infectious Diseases rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Surgical Infectious Diseases rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Antimicrobials, including: o Principles of antimicrobial use o Commonly used antibiotics, including: ƒ Mechanism of action ƒ Pharmacokinetics ƒ Common adverse effects o Mechanisms of antimicrobial resistance • Infection control, including: o Infection/colonization with the following: ƒ Vancomycin-resistant enterococcus ƒ Methacillin-resistant Staphylococcus aureus • Microbiology laboratory, including: o Principles of specimen handling and transport to laboratory o Microbial cultures o Gram staining and other techniques

Page 3.8.1 Learning Objectives (Elective) – Surgical Infectious Diseases

¬ Specific Disease Entities • Central nervous system, including: o Encephalitis o Meningitis • Cardiovascular system, including: o Endocarditis o Bacteremia o Infections related to vascular access devices • Respiratory, including: o Community acquired pneumonia o Nosocomial pneumonia o Sinusitis o Otitis o Pharyngitis o Tuberculosis, including: ƒ Pulmonary ƒ Extrapulmonary • Gastrointestinal, including: o Infectious diarrhea o Peritonitis o Intraabdominal sepsis o Infectious hepatitis o Cholangitis o Liver abscess o Necrotizing pancreatitis • Genitourinary, including: o Urinary tract infections o Sexually transmitted diseases o Prostatitis o Orchitis • Musculoskeletal system, including: o Skin and soft tissue infections, including: ƒ Cellulitis ƒ Abscess ƒ Necrotizing infections, including: à Myonecrosis à Necrotizing fasciitis à Fournier’s gangrene o Osteomyelitis o Septic arthritis o Infected diabetic foot o Burn-related infections • Gynecologic infections, including: o Pelvic inflammatory disease o Septic abortions o Sexually transmitted diseases • Infections in Immunocompromised hosts, including: o HIV/AIDS o Infections in neutropenic patients o Post-splenectomy infections o Infections in transplant recipients o Infections in diabetic patients o Infections in burn patients

Page 3.8.2 Learning Objectives (Elective) – Surgical Infectious Diseases

• Prosthetic materials-related infections, including: o Vascular grafts o Indwelling vascular access devices o Peritoneal dialysis catheters o Breast and other implants o Stents o CSF shunts o Prosthetic heart valves o Pacemakers o Mesh material for hernia repair • Fever of unknown origin • Sepsis syndrome • Medication allergies/reactions

Perform a complete and appropriate assessment of the patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the problems, including interpreting available data and integrating information to generate differential diagnoses and management plans for the patient with an infectious disease

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Surgical Infectious Diseases rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Surgical Infectious Diseases rotation • Appropriately document and disseminate information related to procedures performed and their outcomes

Having completed the Surgical Infectious Diseases rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Obtaining appropriate clinical specimens in appropriate transport media • Interpretation of Gram stains on appropriate clinical specimens • Selection of appropriate imaging studies for the patient with an infectious disease

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the patient with an infectious disease

¾ Communicator At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Page 3.8.3 Learning Objectives (Elective) – Surgical Infectious Diseases

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of any procedures performed during the Surgical Infectious Diseases rotation • Effectively present verbal reports of clinical encounters and medical information during the Surgical Infectious Diseases rotation

¾ Collaborator At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the patient • Work with others to assess, plan, provide and integrate care of the patient with an infectious disease

¾ Manager At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Respond to the needs of the patient with an infectious disease • Identify the health needs of an individual patient

Page 3.8.4 Learning Objectives (Elective) – Surgical Infectious Diseases

¾ Scholar At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Surgical Infectious Diseases rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Surgical Infectious Diseases rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.8.5 Learning Objectives (Elective) – Thoracic Surgery

3.9: THORACIC SURGERY

PREAMBLE The Thoracic Surgery rotation is valuable for the resident planning a career in trauma and critical care. Furthermore, this rotation is an important “early exposure” for the resident interested in pursuing fellowship training in Thoracic Surgery.

GENERAL OBJECTIVES Upon completion of the Thoracic Surgery rotation, the General Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities in those thoracic surgical endeavours pertinent to general surgical practice • Understand and appreciate the role of the thoracic surgeon as a member of the interdisciplinary trauma team

SPECIFIC OBJECTIVES At the completion of the Thoracic Surgery rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Thoracic Surgery rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Thoracic Surgery rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the chest, including: o Larynx and trachea o Chest wall and pleura o Pulmonary anatomy, including: ƒ Lungs ƒ Pulmonary vasculature ƒ Tracheobronchial tree o Mediastinum, including: ƒ Esophagus ƒ Heart and great vessels ƒ Thoracic duct ƒ Thymus • Cardiopulmonary physiology • Esophageal physiology

Page 3.9.1 Learning Objectives (Elective) – Thoracic Surgery

• Patient assessment, including: o Diagnostic imaging, including: ƒ Conventional radiology ƒ CT ƒ MRI ƒ Diagnostic nuclear medicine o Endoscopy, including: ƒ Esophagoscopy ƒ Bronchoscopy ƒ Mediastinoscopy ƒ Thoracoscopy o Pulmonary function testing o Esophageal manometry/pH testing ¬ Specific Disease Entities • Chest trauma, including: o Massive hemothorax o Severe flail chest o Tracheobronchial injuries o Major pulmonary injuries o Pulmonary vasculature injuries o Esophageal injuries, including caustic injury o Diaphragmatic injuries • Lung neoplasia, including: o Primary lung cancer o Pulmonary metastases o Solitary pulmonary nodule • Disease of the pleura, including: o Spontaneous pneumothorax o Pleural effusions o Empyema o Chylothorax o Mesothelioma • Pulmonary embolism • Massive hemoptysis • Thoracic outlet syndrome • Mediastinal neoplasia, including: o Thymoma o Neurogenic tumours o Carcinoid tumours o Germ cell tumours o Soft tissue tumours o Lymphoma • Other lesions of the mediastinum, including: o Cysts o Ectopic thyroid/parathyroid o Sarcoidosis • Esophageal cancer • Gastroesophageal reflux disease, including: o Esophagitis o Barrett’s esophagus o Esophageal strictures • Esophageal motility disorders, including: o Achalasia o Diffuse esophageal spasm o Scleroderma esophagus

Page 3.9.2 Learning Objectives (Elective) – Thoracic Surgery

Perform a complete and appropriate assessment of the thoracic surgical patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the thoracic surgical problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the thoracic surgical patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Thoracic Surgery rotation • Ensure appropriate informed consent is obtained for therapies

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Vascular Surgery rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Thoracic Surgery rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Thoracic Surgery rotation

Having completed the Thoracic Surgery rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Chest tube insertion • Planning, opening and closure of thoracotomy incisions • Planning, opening and closure of thoracoabdominal incisions • Pulmonary biopsy and wedge resection • Minor chest wall procedures • Rigid and flexible esophagoscopy

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the thoracic surgical patient • Arrange appropriate follow-up care services for the thoracic surgical patient

¾ Communicator At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Page 3.9.3 Learning Objectives (Elective) – Thoracic Surgery

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the thoracic surgical patient and family, colleagues and other professionals in a humane and understandable manner

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the thoracic surgical patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Thoracic Surgery rotation • Effectively present verbal reports of clinical encounters and medical information during the Thoracic Surgery rotation

¾ Collaborator At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the thoracic surgical patient • Work with others to assess, plan, provide and integrate care of the thoracic surgical patient

¾ Manager At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Respond to the needs of the thoracic surgical patient • Identify the health needs of an individual patient

Page 3.9.4 Learning Objectives (Elective) – Thoracic Surgery

¾ Scholar At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Thoracic Surgery rotation • Provide effective feedback to faculty, residents and students

¾ Professional At the completion of the Thoracic Surgery rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.9.5 Learning Objectives (Elective) – Urology

3.10: UROLOGY

GENERAL OBJECTIVES Upon completion of the Urology rotation, the general Surgery resident is expected to: • Demonstrate knowledge, clinical and technical skills and decision-making capabilities pertinent to the urologic problems seen in a general surgical practice • Understand and appreciate the role of the urologist as a member of the interdisciplinary trauma and colorectal surgical teams

SPECIFIC OBJECTIVES At the completion of the Urology rotation, the General Surgery resident will have acquired the following competencies and will function effectively as:

¾ Medical Expert At the completion of the Urology rotation, the General Surgery resident will be able to:

Establish and maintain clinical knowledge, skills and attitudes appropriate to the Urology rotation • Apply knowledge of the clinical, socio-behavioural and fundamental biomedical sciences relevant to the Urology rotation

The resident in General Surgery is required to attain sufficient knowledge as follows:

¬ Basic/General Areas • Anatomy of the urogenital tract, including: o Kidneys o Ureters o Bladder o Prostate o Seminal vesicles o Urethra o Male genitalia o Female genitalia o Groin anatomy o Anatomy of the perineum • Urologic assessment, including: o Urinalysis o Biochemistry o Urologic imaging, including: ƒ IVP ƒ Cystography ƒ Retrograde urologic studies ƒ Ultrasound ƒ CT ƒ MRI o Urologic endoscopy o Urodynamic assessment

Page 3.10.1 Learning Objectives (Elective) – Urology

¬ Specific Disease Entities • Urogenital trauma, including: o Renal trauma o Bladder trauma and associated injuries o Urethral trauma and associated injuries o Iatrogenic urethral injury o Injury to the male external genitalia o Injury to the female genitalia • Fournier’s gangrene • Testicular torsion • Urologic problems related to prior pelvic surgery, including: o Neurogenic bladder o Retrograde ejaculation • Nephrolithiasis • Benign prostatic hyperplasia • Urogenital neoplasia, including: o Renal cell carcinoma o Bladder neoplasia o Prostate cancer o Testicular neoplasia, including: ƒ Germ cell tumours ƒ Sex cord-stromal tumours ƒ Mixed germ cell and stromal elements ƒ Adnexal and paratesticular tumours • Adrenal disorders, including: o Cushing’s syndrome o Hyperaldosteronism o Pheochromocytoma o Primary adrenal carcinoma o Metastatic tunours • Scrotal masses, including: o Hydrocele o Spermatocele o Torsion of testicular appendix and epididymis o Varicocele

Perform a complete and appropriate assessment of the Urology patient • Elicit a history that is relevant, concise and accurate • Perform a focused physical examination that is relevant and accurate • Select medically appropriate investigations in a resource-effective and ethical manner • Demonstrate effective clinical problem solving and judgment to address the urologic problems, including interpreting available data and integrating information to generate differential diagnoses and management plans

Use preventive and therapeutic interventions effectively • Implement an effective and prioritized management plan for the Urology patient • Demonstrate effective, appropriate and timely application of therapeutic interventions relevant to the Urology rotation • Ensure appropriate informed consent is obtained for therapies

Page 3.10.2 Learning Objectives (Elective) – Urology

Demonstrate proficient and appropriate use of procedural skills • Demonstrate effective, appropriate and timely performance of diagnostic procedures relevant to the Urology rotation • Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to the Urology rotation • Ensure appropriate informed consent is obtained for procedures • Appropriately document and disseminate information related to procedures performed and their outcomes • Ensure adequate follow-up is arranged for procedures performed • Compile and maintain an accurate and complete electronic data base for all operative procedures performed on the Urology rotation

Having completed the Urology rotation, the General Surgery resident will be able to demonstrate knowledge and technical competence in performing the following procedures: • Urinary catheterization, including suprapubic bladder catheterization • Vasectomy • Orchiectomy • Ligation of spermatic veins for varicocele • Repair of hydrocele • Repair of spermatocele • Elective open repair of inguinal hernia • Repair of ureteric injuries (depending on resident’s level of training and experience) • Open nephrectomy (depending on resident’s level of training and experience) • Laparoscopic nephrectomy (depending on resident’s level of training and experience)

Seek appropriate consultation from other health professionals • Demonstrate insight into his/her own limitations of expertise by self-assessment • Demonstrate effective, appropriate and timely consultation of another health professional as needed for optimal care of the Urology patient • Arrange appropriate follow-up care services for the Urology patient

¾ Communicator At the completion of the Urology rotation, the General Surgery resident will be able to:

Develop rapport, trust and ethical therapeutic relationships with patients and families • Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty and empathy • Respect patient confidentiality, privacy and autonomy • Listen effectively

Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues and other professionals • Seek out and synthesize relevant information from other sources such as the patient’s family, caregivers and other professionals

Accurately convey relevant information and explanations to patients and families, colleagues and other professionals • Deliver information to the patient and family, colleagues and other professionals in a humane and understandable manner

Page 3.10.3 Learning Objectives (Elective) – Urology

Convey effective oral and written information • Maintain clear, accurate, appropriate and timely records of clinical encounters and operative procedures involving the patients • Maintain an accurate, complete and up-to-date electronic database (log) of operative procedures performed during the Urology rotation • Effectively present verbal reports of clinical encounters and medical information during the Urology rotation

¾ Collaborator At the completion of the Urology rotation, the General Surgery resident will be able to:

Participate effectively and appropriately in an interprofessional healthcare team • Recognize and respect the diversity of roles, responsibilities and competences of other professionals in the management of the Urology patient • Work with others to assess, plan, provide and integrate care of the patient

¾ Manager At the completion of the Urology rotation, the General Surgery resident will be able to:

Manage his/her professional and personal activities effectively • Set priorities and manage time to balance professional responsibilities, outside activities and personal life • Employ information technology effectively (e.g. electronic surgical procedure database)

Demonstrate an understanding of cost-effectiveness in patient management • Utilize hospital resources wisely when managing patients

Serve in leadership roles, as appropriate • Participate effectively at teaching rounds and other meetings

¾ Health Advocate At the completion of the Urology rotation, the General Surgery resident will be able to:

Respond to the needs of the patient • Identify the health needs of an individual patient

¾ Scholar At the completion of the Urology rotation, the General Surgery resident will be able to:

Maintain and enhance professional activities through ongoing learning • Pose an appropriate learning question • Access and interpret the relevant evidence • Integrate new learning into development as a general surgeon

Critically evaluate medical information and its sources and apply this appropriately to clinical decisions • Critically appraise the evidence in order to address a clinical question • Integrate critical appraisal conclusions into clinical care

Facilitate the learning of students and residents • Demonstrate an effective presentation while assigned to the Urology rotation • Provide effective feedback to faculty, residents and students

Page 3.10.4 Learning Objectives (Elective) – Urology

¾ Professional At the completion of the Urology rotation, the General Surgery resident will be able to:

Demonstrate a commitment to patients through ethical practice • Exhibit appropriate professional behaviours, including honesty, integrity, commitment, compassion, respect and altruism • Appropriately manage conflicts of interest • Recognize the principles and limits of patient confidentiality • Maintain appropriate relations with patients

Demonstrate a commitment to physician health • Balance personal and professional priorities • Strive to heighten personal and professional awareness and insight

Page 3.10.5

Section 4: Other Components of Program Other Components of Program – Academic & Scholarly

4.1: ACADEMIC & SCHOLARLY

The academic and scholarly content of the General Surgery Residency Training Program complement the resident’s clinical exposure and enable him/her to fulfill all of the roles of the specialist general surgeon. Through these scholarly activities, including seminars, rounds and conferences the resident acquires an in- depth understanding of basic mechanisms of normal and abnormal states and the ability to apply current knowledge to general surgical practice.

ROUNDS AND SEMINARS Wednesday has been designated as “rounds day.” The General Surgery residents must attend these sessions which include:

¾ Department of Surgery Grand Rounds These rounds are held 0745-0845 hrs at the Health Sciences Centre and St. Boniface General Hospital with periodic television linkage between the two sites. Important topics are presented by faculty, visiting professors and residents.

¾ Morbidity and Mortality/Complication Rounds These sessions are held 0900-1000 hrs at the St. Boniface General Hospital and the Health Sciences Centre. Complicated cases are presented and this is followed by lively and open discussion among residents and attending surgeons.

¾ Combined Gastrointestinal Rounds These sessions are held 1130-1230 hrs. Interesting cases are presented by the residents and are discussed among gastroenterology faculty and clinical fellows and the general surgery faculty and residents.

¾ Academic Afternoon Seminars The General Surgery academic afternoon (half-day) held 1300-1700 hrs (Wednesday) is the major formal teaching focus for the resident. Attendance is mandatory and the resident is relieved of all clinical responsibilities during this period of time (protected time). The activities include:

Practical Anatomy Seminar/Laboratory Session These sessions are held 1300-1400 hrs and include a didactic lecture prepared and presented by the resident followed by dissection in the anatomy laboratory under the supervision of anatomists and surgeons.

Principles of Surgery Seminar/Lecture Series These seminars are held 1400-1600 hrs and cover the topics outlined in the Objectives of Core Training in Surgery . The Postgraduate Medical Education Committee (Faculty of Medicine) at the University of Manitoba provides seminars and lectures for residents of all specialties covering the following CanMEDS competencies: • Communication and consultation skills • Teaching skills (TIPS workshop) • Principles and practice of quality assurance/improvement • Biomedical ethics • Medicolegal issues

Page 4.1.1 Other Components of Program – Academic & Scholarly

• Biostatistics and critical appraisal of research methodology and medical literature • Management and administration skills • Self-assessment and self-directed life-long learning

Clinical Problems in Surgery Seminar These lectures are held 1600-1700 hrs and cover the basic and clinical sciences relevant to general surgery. Topics are prepared and presented by the resident under the guidance and supervision of a faculty member who has expertise with respect to the topic. All major topics are covered over the course of each resident’s time in the Program.

OTHER ROUNDS AND SEMINARS There are many valuable rounds and seminars held throughout the week. The resident is encouraged to attend these sessions if time permits. These include:

¾ Combined Medical/Surgical Gastrointestinal Rounds These academic seminars held twice per month on alternate Thursdays 1200-1300 hrs are linked between the Health Sciences Centre and St. Boniface General Hospital. Interesting topics are presented by gastroenterologists, surgeons, residents and clinical fellows.

¾ Other For a complete list of rounds and seminars available to attend, please consult the individual academic departments within each hospital.

VISITING PROFESSOR PROGRAM Visiting experts of national and international repute are invited to present at Surgical Grand Rounds and often spend time with the residents discussing cases or topics of interest.

JOURNAL CLUB The General Surgery Journal Club is held on the first Monday evening of each month. It follows the curriculum of the Evidence Based Reviews in Surgery, a joint project of the Canadian Association of General Surgeons and the American College of Surgeons, designed to teach critical appraisal skills to practicing surgeons and trainees. All attending surgeons are encouraged to attend so that the residents may benefit from their experience and knowledge. Resident attendance at the Journal Club is mandatory unless he/she is on-call.

SURGICAL SKILLS COURSES The resident participates in several surgical skills courses while enrolled in the Program. These are designed to facilitate the mastery of basic and advanced surgical skills and techniques. These include:

¾ Introduction to Basic Surgical Skills This is an introductory course for the PGY-1 resident to learn suturing, surgical stapling and tissue handling and approximation techniques.

¾ Gut Suture Anastomosis This course offers the PGY-2 resident the opportunity to learn and practice the more advanced suturing techniques.

Page 4.1.2 Other Components of Program – Academic & Scholarly

¾ Gut Staple Anastomosis This course offers the PGY-2 resident the opportunity to learn and practice bowel stapling techniques

¾ Introduction to Minimal Access Surgery This course offers a didactic component and a porcine laboratory and introduces the resident to the principles of minimal access surgery with emphasis on laparoscopic cholecystectomy.

¾ Advanced Course in Minimal Access Surgery This course is offered to the resident at a more senior level of training. Emphasis is placed on more advanced minimal access techniques such as hernia repair, antireflux operations, common bile duct exploration, colorectal surgery, nephrectomy, splenectomy and suturing techniques. This course includes didactic and porcine practical laboratory sessions.

¾ Hernia Skills Course This course is offered to the resident at the PGY-2/PGY-3 level. It covers the technical aspects of hernia repair and includes didactic and practical sessions.

¾ Vascular Skills Course This course covers the important technical skills such as vascular anastomosis. It is offered to the resident at the PGY-2 level.

PATHOLOGY PROGRAM This is a mandatory self-directed learning program in Pathology for the PGY-1 resident. He/she must complete this program during the first year of training. The Pathology program includes a web-based tutorial and textbook references. The program also serves as a ready reference for residents at all levels of training.

LOCAL NATIONAL AND INTERNATIONAL CONFERENCES AND COURSES Residents are encouraged to prepare and submit scientific papers for presentation at local, national and international meetings. The following regulations apply: • The Program Director must approve the application to attend the meeting • In the event of a resident conflict, permission to attend a meeting depends on the level of training of the resident, the number of meetings already attended and the degree of resident involvement at the meeting • Financial assistance for the resident to attend the meeting is provided only if it is available; there is a limit to the amount of funding available for each resident in the Program • Additional funding may be available from the Faculty of Medicine for the resident to attend a meeting where he/she is presenting a scientific paper

Page 4.1.3 Other Components of Program – Career Planning

4.2: CAREER PLANNING

The Program Director has the responsibility of assisting the General Surgery resident in planning his/her career in General Surgery. Career planning strategies include: • Discussion of the resident’s career plans during the scheduled interviews • Informal discussions pertaining to career plans with the resident • Assisting the resident in identifying areas of interest and excellence • Informing the resident of available fellowship opportunities • Informing the resident of available practice opportunities • Providing accurate and timely certification documents for the resident • Providing timely and supportive references for the resident • Providing the support for the resident to interview for fellowship opportunities

Ultimately it is the resident who is responsible for his/her career in General Surgery. Therefore, the resident is advised to begin the process of career planning as early as possible.

Page 4.2.1 Other Components of Program – Evaluation of Faculty

4.3: EVALUATION OF FACULTY

Teaching staff appointed by the General Surgery Residency Training Program at the University of Manitoba must exercise the dual responsibility of providing high quality and ethical patient care and excellent teaching. Evaluation of the teaching performance of the faculty is very important in maintaining high academic standards within the Program and in promoting a learning environment that is free of intimidation, harassment and abuse. The resident must complete the Faculty Evaluation Form (available from the Surgical Education Office) for each attending surgeon with whom he/she has worked while assigned to a particular surgical unit during each academic year in the Program and promptly submit the form to the Surgical Education Office. The identity of the resident completing the evaluation form is kept strictly confidential (the resident‘s signature is not required). The Summary Reports of each faculty evaluation are reviewed by the Program Director and if necessary, by the General Surgery Postgraduate Committee. Summative evaluation of a member of the Program teaching faculty is utilized for the following: • Review and discussion of his/her teaching performance at the annual interview with the Head of the Section of General Surgery • Promotion of faculty members with excellent teaching performance • Remedial Training (TIPS course) of faculty members with below average teaching performance • Dismissal of faculty members with consistently poor teaching performance • Dismissal of abusive faculty members

Page 4.3.1 Other Components of Program – Evaluation of Resident Performance

4.4: EVALUATION OF RESIDENT PERFORMANCE

PREAMBLE The purpose of resident evaluation is to identify areas of strength and weakness in knowledge (cognitive), clinical and technical skills (cognitive) and attitude (affective). The feedback of his/her strengths enhances self-esteem and stimulates further achievement. Deficiencies are addressed by planned remediation in collaboration with the resident, the attending surgeons and other faculty.

IN-TRAINING EVALUATION The in-training evaluation system is based on the rotation-specific learning objectives. Formative evaluation of the resident’s performance on a particular rotation occurs regularly by direct observation. At mid-rotation any major deficiencies in performance are discussed with the resident (by the Service Chief or designate) so that these might be addressed during the rotation. If there are no major deficiencies it is the resident’s responsibility to arrange a meeting with the Service Chief (or designate) to discuss his/her performance. At the end of each rotation the resident’s summative evaluation is documented in the In-Training Evaluation Report (ITER). The ITER must be reviewed and signed by the resident, Service Chief (or designate) and the Program Director. The resident has the opportunity of appealing the ITER by completing a written document available through the Surgical Education Office. It is the responsibility of the resident to arrange an exit-interview with the Service Chief (or designate) at the end of the rotation, for timely feedback. Problems and deficiencies are brought to the attention of the Program Director for timely and honest discussion with the resident and for further action such as remediation.

MEETING WITH THE PROGRAM DIRECTOR The resident formally meets with the Program Director twice per year to discuss his/her progress, problems, curriculum planning and career development. The resident can meet formally with the Program Director at any time to discuss matters pertaining to resident evaluation. The resident is able to informally discuss issues related to evaluation with the Program Director at any time.

EVALUATION OF SPECIFIC DOMAINS OF LEARNING

¾ Knowledge (Cognitive) These skills are assessed by: • Direct observation of resident performance • Oral examinations at the completion of general surgery rotations (PGY-2 level and above) • In-training examinations (CAGS) where resident performance is compared within level of training, within the Program and in relation to residents in other Canadian general surgery programs

¾ Clinical and Technical Skills These skills are assessed by: • Direct observation of resident performance and incorporated into the in-training evaluation system

Page 4.4.1 Other Components of Program – Evaluation of Resident Performance

¾ Affective Skills (Attitude) These skills are assessed by: • Direct observation of resident performance • Interviews with peers, supervisors, allied health personnel and patients and their families (360 degree assessment)

¾ Communication Skills These skills are assessed by: • Direct observation of resident interactions with patients and their families and colleagues • Scrutiny of written communications including clinical and scientific reports and consultation letters to referring physicians • Observation of the resident’s understanding of issues related to age, gender, culture and ethnicity

¾ Collaboration/Interpersonal Skills These skills are assessed by: • Observation of the resident as a member of a health care team • Scrutiny of the resident’s utilization of consultations with other professionals

¾ Teaching Skills These skills are assessed by: • Written evaluation by physicians in training • Direct observation of the resident in seminars, lectures and case presentations

ANNUAL PROMOTION Promotion of the resident to the next level of training is based on his/her overall performance during the academic year. This is reviewed and authorized by the Program Director.

FINAL EVALUATION At the conclusion of the resident’s training in the Program the Program Director and the General Surgery Residency Postgraduate Committee discuss his/her overall performance and complete and submit the Final In-Training Evaluation Report (FITER) to the Royal College of Physicians and Surgeons of Canada, confirming that the resident is competent and capable of independent general surgical practice.

RESIDENT REMEDIATION/PROBATION In the event that the resident encounters difficulties that require in-depth correction, he/she may require a period of remediation with specific objectives and conditions. Upon completion of this period by the resident, the Program Director provides a report to the General Surgery Postgraduate Committee whereby a decision is made with respect to successful completion of the remediation contract. A period of further remediation or probation may be recommended. The Associate Dean of Postgraduate Medical Education of the Faculty of Medicine, University of Manitoba is involved in the entire process. The Faculty of Medicine follows a specific protocol for both remediation and probation for the benefit of all of the involved parties.

Page 4.4.2 Other Components of Program – Evaluation of Resident Performance

APPEAL MECHANISM If the resident feels that his/her evaluation(s) have been unfair or inaccurate, he/she can appeal to the Program Director directly in writing. The Program Director reviews the situation and resolves the dispute with the assistance and advice of the General Surgery Postgraduate Committee and the Director of Postgraduate Surgical Education. The Program Director may refer a resident appeal to the Faculty of Medicine Postgraduate Medical Education Executive Committee for review, where appropriate.

Page 4.4.3 Other Components of Program – Evaluation of Services/Rotations

4.5: EVALUATION OF SERVICES/ROTATIONS

Evaluation of the quality of the educational experiences within the General Surgery Residency Training Program is very important. The opinions of the resident are among the factors taken into consideration in improving/modifying/ deleting rotations/services and other educational experiences in the Program. The resident is encouraged to complete the Service/Rotation Evaluation Form (available from the Surgical Education Office) confidentially (resident’s signature is not required) and to submit the form to the Surgical Education Office promptly. The Program Director reviews the completed evaluation forms and discusses the results with the General Surgery Postgraduate Committee.

Page 4.5.1 Other Components of Program – Master of Science in Surgery Program

4.6: MASTER OF SCIENCE IN SURGERY PROGRAM

PURPOSE The Master of Science Degree in Surgery Program is a one year period of formal research training in preparation for a career as a clinician-investigator and is undertaken by the resident who is interested in academic surgery.

ELIGIBILITY The Master of Science in Surgery Program is available to all surgical residents at the University of Manitoba. Supervisors of the research projects do not have to be surgeons but they must possess the qualifications to oversee the Master’s candidate.

APPLICATION PROCEDURE A resident interested in the Master of Science Degree in Surgery Program must make an appointment with the Coordinator for Surgical Education Programs to discuss the process. An information package will be provided at the time of the appointment. The Master of Science research proposal must be approved by the Research Chair of the Department of Surgery before application to Faculty of Graduate Studies can be made.

RULES OF CONDUCT • The resident participating in the Master of Science Degree in Surgery Program must: o Conduct twelve months of research work under the direction of the Director of Research of the Department of Surgery at the University of Manitoba o Take courses in biostatistics o Attend specified surgical rounds o Submit a major thesis on the research project o Demonstrate to an examining committee a satisfactory thesis and adequate knowledge of the subject studied o Limit clinical activity during the Master of Science in Surgery Program • The Program Director (in General Surgery) must: o Identify the applicant as a potential clinician-investigator o Assist the resident in choosing a research supervisor for the applicant o Provide full salary support for the resident during his/her time in the Master of Science in Surgery Program • The Research Supervisor must: o Provide appropriate guidance and direction to the resident in attaining his/her research goal o Provide appropriate research space and funding to support the proposed research • The Director of Research of the Department of Surgery must: o Monitor the progress of the Master candidate and help to resolve any problems which may arise

Page 4.6.1 Other Components of Program – Master of Science in Surgery Program

COURSE OFFERINGS Course Number Description Credit SURG7010 Surgery: Major Course in Surgical Problems (Surgery Grand Rounds) 6 SURG7020 Surgery: Surgical Subspecialty Rounds 6 SURG7030 Advanced Surgery 3 SURG7040 Surgical Epidemiology and Biostatistics 3 If the above biostatistics course is not available, the equivalent would be the following: SURG7470 Biostatistics I 3 Additionally, the resident should consider taking the following course: 093.7480 Biostatistics II 3

The resident is advised to consult the Surgical Education Office if wishing to pursue the Master of Science in Surgery. For more information, contact mailto:[email protected]

Page 4.6.2 Other Components of Program – Research Activities

4.7: RESEARCH ACTIVITIES

The General Surgery resident is must participate in research activities during the course of the Program. The Program has a Research Coordinator whom the resident can contact for guidance and advice with respect to research ideas and projects. Furthermore, the Program has access to a statistician who is a member of the Department of Surgery at the University of Manitoba and is available to assist the resident with respect to statistical analysis of his/her research. The resident is advised to review the Resident Research Program section on the General Surgery Residency Program website. This section outlines the Research Objectives and serves as a guide to resident research endeavours and resources. When considering a research project or proposal, the resident should be able to: • Generate a research question (basic science, clinical, population health or combination) • Develop a proposal to answer the research question: o conduct an appropriate literature search o assimilate and critically evaluate the literature o identify, consult and collaborate with appropriate experts to undertake the research project • Propose appropriate methods for conducting the research • Undertake the proposed research • Propose a solution to the research question • Disseminate and defend the results of the research • Identify future research opportunities of questions that arise from the results

Program research activities include:

CLINICAL RESEARCH PROJECTS The resident is encouraged to complete at least two research projects for presentation at the annual Research Day and possibly for national or international presentation and publication during the course of the Program. The projects are undertaken with the required assistance of faculty with expertise in the area of interest. Overall supervision is maintained by the General Surgery Residency Training Program Research Coordinator.

MASTER OF SCIENCE DEGREE IN SURGERY PROGRAM The Master of Science in Surgery Program is a one year period of formal research training supplemented by courses in biostatistics for the General Surgery resident who is interested in an academic career as a clinician-investigator. The resident is encouraged to choose an area of research that complements his/her career plans. Funding for the research project originates from the research grant of the faculty investigator while the resident’s salary during the one year of research originates from the General Surgery Residency Training Program. It is expected that the resident will complete his/her thesis following the research component of the Master of Science Degree in Surgery Program For further details, the resident should refer to the separate section entitled: Master of Science Degree in Surgery Program.

PRINCIPLES OF SURGERY LECTURE SERIES Lectures arranged by the Faculty of Medicine cover topics in biostatistics and critical appraisal of the medical literature. They are integrated into the Principles of Surgery Lecture Series and are presented during the academic half-day.

Page 4.7.1 Other Components of Program – Research Activities

JOURNAL CLUB The General Surgery Journal Club allows residents an informal milieu in which to acquire skills in biostatistics and critical appraisal of the medical literature. The Journal Club follows the format and curriculum of the Canadian Association of General Surgeons Evidence Based Reviews in Surgery.

SCIENTIFIC MEETINGS The resident is encouraged to prepare and present scientific papers at local, national and international scientific meetings.

ROLE MODELING The resident interacts with faculty role models who actively participate in basic and clinical research and produce scientific publications.

Page 4.7.2 Other Components of Program – Resident Resources

4.8: RESIDENT RESOURCES

GENERAL SURGERY RESIDENCY TRAINING PROGRAM WEBSITE • Information about the Program • Bulletin board of events and updates • Online links to educational sites • Online Program learning objectives (“Blue Book”) • Address: www.umanitoba.ca/faculties/medicine/units/surgery

RESIDENT RESOURCE ROOMS

¾ Health Sciences Centre • Location: GF438 • Telephone: 787-2433 • Resources: o Computer with online access o Textbooks o Journals

¾ St. Boniface General Hospital • Location: A7006 • Telephone: 235-3429 • Resources: o Computer with online access o Textbooks o Journals

AUDIOVISUAL SERVICES

¾ Health Sciences Centre • Location: MS251 (Thorlakson Building) • Telephone: 787-2458

¾ St. Boniface General Hospital • Location: School of Nursing • Telephone: 237-2810

Page 4.8.1 Other Components of Program – Resident Resources

LIBRARIES

¾ University of Manitoba

Neil John McLean Health Sciences Library • Location: Brodie Centre, Health Sciences Campus • Telephone: o General information: 789-3342 or 789-3464 o References/computer searches: 789-3460 o Hours of service: 474-9770 (recording)

Carolyn Sifton-Helene Fuld Library • Location: St. Boniface General Hospital Campus • Hours of service: 0800-1700 hrs. (Mon-Fri); 24-hr. access available • Telephone: o General information: 237-2807 o Fax: 235-3339

Elizabeth Dafoe Library • Location: Fort Garry Campus • Telephone: o Circulation: 474-9544 o Reference: 474-9844 o Reserve: 474-9544 o Hours of service: 474-9770 (recording)

Science Library • Location: Fort Garry Campus • Telephone: o General information: 474-9281 o Hours of service: 474-9770 (recording)

LABORATORY RESOURCES

¾ Surgical Skills Laboratory • Location: St. Boniface Research Centre • Resources: Large animal operating rooms (fully equipped)

¾ Anatomy Facilities • Location: Basic Medical Sciences Building • Resources: o Cadaver dissection o Prosected materials o Plastic models o Audiovisual aids

Page 4.8.2 Other Components of Program – Stress Management

4.9: STRESS MANAGEMENT

Residency training can be a time of tremendous stress for the resident and his/her family. Signs of stress include: • Depression • Alcoholism • Drug dependency/addiction • Marital strife/difficulties • Suicide ideation

There are a number of support programs available to the resident and faculty members. These include:

PROGRAM DIRECTOR/FACULTY SUPPORT Stress-related problems should be brought to the attention of the Program Director or a “trusted” faculty member or mentor. Guidance and support will be provided promptly and confidentially.

FACULTY COUNSELLING/PARIM AT RISK SERVICE The Faculty of Medicine and PARIM jointly sponsor the Faculty Counselling/PARIM at Risk Service for faculty members and residents. Psychiatrists provide urgent counselling/support on a confidential basis. • Telephone: 789-3799 or 789-3328 (twenty-four hrs)

UNIVERSITY OF MANITOBA COUNSELLING SERVICE (HEALTH SCIENCES CAMPUS) The University of Manitoba Counselling Service is organized by the Department of Psychology. Two counselors provide support and guidance to residents and faculty members. • Location: S207 Medical Services Building • Telephone: 789-3857 or 474-8594 or 474-8592 (receptionist)

PHYSICIANS AT RISK CRISIS LINE • Telephone: 789-3799 (twenty-four hrs)

Page 4.9.1

Section 5: Forms Received in Program Office: Faculty of Medicine ______Department of Surgery - Surgery Education Programs

HOLIDAY: CHRISTMAS/NEW YEAR’S REQUEST

(Circle) NAME PGY LEVEL 1 2 3 4 5 6 (PLEASE PRINT CLEARLY) HOME PROGRAM

SELECT ONE CHRISTMAS: December __ 200_ to December __ 200_ NEW YEAR: December __ 200_ to January __ 200_ *OTHER: 3 weekdays and 1 weekend (Sat/Sun only) *Dates must be specified: REASON FOR SELECTION ASSIGNED SERVICE SIGNATURE Date

APPROVALS SELECTION APPROVED: ______YES _____NO if no, please provide reason:

CHIEF RESIDENT Date (Signature)

I HAVE REVIEWED AND AGREE WITH THE RECOMMENDATION OF THE CHIEF RESIDENT:

SERVICE CHIEF Date (Signature)

In order to assign this holiday period in a timely fashion, please submit this form no later than SEPTEMBER 200 (see “How to Submit this Form”). If not submitted by this deadline, the Chief Resident will assign your holiday period. In the event one holiday period has been chosen by the majority, the Chief Resident will make the decision based on a first-come-first-served basis. Please note, if you are on vacation during Period #7, this form must be completed to advise your Program Director when you wish to take these five consecutive days off.

HOW TO SUBMIT THIS FORM If you are 1) A surgical resident on a general surgery service, submit to the Surgical Education Office.

2) Scheduled in your home service, submit to your Program Office.

3) A non-surgical resident on any surgical service, submit to the Surgical Education Office.

4) On an elective or other non-surgical rotation, copy for your home Program Office and submit the original to the Service.

5) Requesting time off other than at Christmas or New Year’s, submit to your Program Office for approval by your Program Director.

E:\Christmas - New Years Request Blank Copy.doc All Education Leave must be pre-approved. Unless otherwise mutually agreed four (4) weeks notice for education leave shall be given by the resident.

Faculty of Medicine Department of Surgery / Postgraduate Surgery Education Programs

EDUCATION LEAVE REQUEST FORM

Resident Name PGY Level Home Residency Program Away From Service: During Period #

CONFERENCE: Title Location Conference Dates Depart: Return: (Dates you are requesting to be away) CHECK ONE OF THE FOLLOWING: F Presenter Presentation Title F Attendee Attended in previous year(s) No F Yes F When If Attendee checked, reason for attending

Resident Signature Date

I am aware of this request for an Education Leave and (please check one) give F do not give F consent that this resident pursue the appropriate approval to be away from the service affected.

DATE Home Program Director Prior to Approval from Service, (signature and please print last name) Please return this form to: ______for processing. APPROVAL FROM SERVICE Based on a review of all requests listed below for this period, I Recommend F Do not recommend F to the Service Chief a leave of absence. CHIEF RESIDENT DATE (signature and please print last name) SERVICE CHIEF: F APPROVED F NOT APPROVED DATE (signature and please print last name)

FOR OFFICE USE ONLY DATE RECEIVED FOR PROCESSING: G Program Education Request for Time Away Residents on Service PGY Level Half-Day (if yes, list dates) Other events, exams, etc

E:\Education Leave Request PG Surg Educ Progs 2006.doc

GENERAL SURGERY RESIDENCY TRAINING PROGRAM

IN-TRAINING EVALUATION REPORT

- ANATOMY ROTATION -

Name: Rotation: Anatomy Hospital: HSC Period: Level of Training 1 Supervisor: Dr J Thliveris Dates: Conference / Sick Time F No F Yes If yes, list dates: EXPECTATIONS Please check one Generally Meets Meets Generally *Inconsistently *Rarely Meets *Consistently *Consistently Not Assessed Assessed Not Sometimes Exceeds Exceeds A rationale must be provided to support ratings with asterisks. Meets

MEDICAL EXPERT Proficiency in Basic knowledge of general / surgical anatomy Performance of Technical Procedures: including knowledge of procedures, knowledge of surgical anatomy, tissue handling COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

PROCEDURES & TECHNICAL SKILLS Proficiency in: Tissue handling, knowledge of procedures, independence and quality of dissection COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

COMMUNICATOR Proficiency in Providing clear and thorough explanation of dissection Oral Presentation of Anatomy: preparation, knowledge of topic and clear and succinct presentation at weekly oral exams COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

PROFESSIONAL Proficiency in: Respect for the Deceased: shows appropriate respect for the dignity of the deceased Insight: demonstrates awareness of own limitations; seeks advice when necessary Sense of Responsibility: dependability COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

E:\General Surgery CANMEDS Anatomy Evaluation.doc Original: June 2004 / REVISED: April 2005 / August 2005

PAGE 2 Weekly Oral Exams on Assigned Dissections

Week #1: Head & Neck and Breast Pass _____ Fail _____ Week #2: Extremities Pass _____ Fail _____ Week #3: Abdomen Pass _____ Fail _____ Week #4: Abdomen and Groin Pass _____ Fail _____ END OF ROTATION ORAL EXAM PASS ___ FAIL ___ Please give examples and/or comments on resident’s performance and competency in final exam:

EXPECTATIONS Please check one Generally Meets Meets Generally *Inconsistently *Rarely Meets *Consistently *Consistently Not Assessed Assessed Not Sometimes Exceeds Exceeds Meets Meets OVERALL EVALUATION OF RESIDENT’S PERFORMANCE

OVERALL COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

STRENGTHS:

WEAKNESSES:

This evaluation was completed by: _____ A Committee _____One Individual (please name) ______

I (we) have discussed this assessment with the resident: __ Yes __No (Please give reason if not discussed with resident)

Name of Supervisor (please print) ______

Signature of Supervisor______Date ______

Resident’s comments:

Signature of Resident______Date ______

Any concerns about the above assessment should be addressed by completing the Request for Review of Assessment form available in the Surgical Education Office (GC401) and returned by the resident within two (2) weeks of the date of the evaluation. Reviewed by Program Director:

Signature______Date ______

E:\General Surgery CANMEDS Anatomy Evaluation.doc Original: June 2004 / REVISED: April 2005 / August 2005

GENERAL SURGERY RESIDENCY TRAINING PROGRAM

University of Manitoba

IN-TRAINING EVALUATION REPORT

Name: Rotation: Hospital:

Level of Training: Period: Supervisor:

Conference/Sick Time F No F Yes If yes, list dates:

EXPECTATIONS Please check one Generally Meets *Inconsistently *Inconsistently *Rarely Meets Not Assessed *Consistently *Consistently Sometimes Exceeds Exceeds A rationale must be provided to support ratings with asterisks. Meets

MEDICAL EXPERT Proficiency in Basic and clinical knowledge Data Gathering: interviewing skills, and taking a relevant history Data Gathering: performing an appropriate physical examination Use of appropriate diagnostic tests Diagnostic / therapeutic planning Clinical judgment / decision-making Intra-operative decision-making / independence (will depend on level of training) Emergency Care: functioning effectively in emergency situations Ambulatory Care: functioning effectively in outpatient setting Performance of Technical Procedures: including knowledge of procedures, knowledge of surgical anatomy, tissue handling and independence COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

PROCEDURES & TECHNICAL SKILLS Proficiency in: a) b) c) d) e) f) g) h) i) COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

Page 2

EXPECTATIONS Please check one Generally Meets *Inconsistently *Inconsistently *Rarely Meets Not Assessed *Consistently *Consistently Sometimes Exceeds Exceeds A rationale must be provided to support ratings with asterisks. Meets

COMMUNICATOR Proficiency in Establishing a therapeutic relationship with patients and communicating well with families Providing clear and thorough explanation of diagnosis, investigation and management Establishing good relationship with peers and health and other professionals Oral Presentation Skills with the Health Care Team: clear and succinct presentation of patient assessments and management plans Records and Reports: including written records, consultations and dictation of operative reports completed accurately, clearly and timely COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

COLLABORATOR Proficiency in: Team Relationships: ability to work harmoniously with colleagues and delegates appropriately Consultations: consults effectively with other physicians and health care professionals COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

MANAGER Proficiency in: Resource Allocation: uses available resources effectively and considers alternate management options; ordering tests appropriately Organization of Workload: works effectively / efficiently; ability to prioritize, delegate and manage simultaneous tasks Knowledge of principles of quality assurance and outcome measures Attention to Details: good follow-up on delegated tasks Understanding and utilization of information technology such as methods of searching medical databases COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

Page 3

EXPECTATIONS Please check one Generally Meets *Inconsistently *Inconsistently *Rarely Meets Not Assessed *Consistently *Consistently Sometimes Exceeds Exceeds A rationale must be provided to support ratings with asterisks. Meets

HEALTH ADVOCATE Proficiency in Patient Intervention: intervenes on behalf of patients with respect to their care Patient Safety: recognizes and responds appropriately in advocacy situations particularly with regard to patient safety Guidelines: demonstrates knowledge of the guidelines / standards concerning surgical practice in Canada COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

SCHOLAR Proficiency in: Learning: demonstrates a commitment to continuing personal education Critical Appraisal: ability to critically appraise sources of medical information and uses evidence in clinical decision-making Teaching: education of patients and other health care professionals including presentation of rounds COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

PROFESSIONAL Proficiency in: Patient-Physician Relationships: ability to establish effective relationships with patients and families Professional Relationships: develops effective professional relationships with health and other professionals Sense of Responsibility: delivers highest quality of care with integrity and honesty Sense of Compassion: demonstrates compassion in providing care to patients and their families Ethics: demonstrates an understanding of principles of bioethics and applies them in clinical situations Insight: demonstrates awareness of own limitations; seeks advice when necessary Work ethic / dependability COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

Page 4

OVERALL COMMENTS: Please give examples and elaborate on strengths and weaknesses identified

STRENGTHS:

WEAKNESSES:

EXPECTATIONS Please check one Generally Meets *Inconsistently *Inconsistently *Rarely Meets Not Assessed *Consistently *Consistently Sometimes Exceeds Exceeds OVERALL EVALUATION OF RESIDENT’S PERFORMANCE Meets

This evaluation was completed by: _____ A Committee _____One Individual (please name) ______

_____ Other: ______

We have discussed this assessment with the resident:

_____ Yes ____No (Please give reason if not discussed with resident)

Name of Supervisor (please print) ______

Signature of Supervisor______Date ______

Resident’s comments:

Signature of Resident______Date ______Any concerns about the above assessment should be addressed by completing the Request for Review of Assessment form available in the Surgical Education Office (GC401) and returned by the resident within two (2) weeks of the date of the evaluation. Reviewed by Program Director:

Signature______Date ______

T:\Forms\Evaluation Forms\General Surgery CANMEDS Evaluation.doc REVISED: June 2004 (SE Office)

GENERAL SURGERY RESIDENCY PROGRAM

MID-ROTATION EVALUATION REPORT

Name: Training Level: Hospital: Period: Rotation: Supervisor: Dr.

EXPECTATIONS Please check one Generally Meets Meets Generally *Inconsistently *Rarely Meets *Consistently *Consistently Not Assessed Assessed Not Sometimes Exceeds Exceeds

A rationale must be provided to support ratings with asterisks. Meets

MEDICAL EXPERT Rationale / Recommendations

COMMUNICATOR Rationale / Recommendations

COLLABORATOR Rationale / Recommendations

MANAGER Rationale / Recommendations

HEALTH ADVOCATE Rationale / Recommendations

SCHOLAR Rationale / Recommendations

PROFESSIONAL Rationale / Recommendations

MIDWAY ASSESSMENT Please check one F The resident’s performance is satisfactory F The resident’s performance requires improvement and needs attention in the areas specified (comments required above) F The resident’s performance is unsatisfactory and presents a risk for failing this rotation (comments required above) OVERALL COMMENTS (use reverse side if necessary)

Was this evaluation reviewed with the resident? F Yes F No

RESIDENT RESPONSE Did you receive verbal feedback? F Yes F No Do you agree with outcome of this evaluation? F Yes F No* (*if “No” comments required on reverse) Resident Signature Program Director Date Date

T:/Forms/Evaluation Forms/General Surgery CANMEDS Mid-Rotation.doc Created: February 2006 (SE Office) Received in Program Office: ______Faculty of Medicine Department of Surgery - Surgery Education Programs

RESIDENT VACATION REQUEST

This form is to be used only if your vacation period(s): 1) has been scheduled and you are requesting a change; or 2) have not been scheduled by July 1st. All vacation requests must be received by the Program Director no later than September 15th or the vacation period will be assigned (as stated in the PARIM Agreement) and can be 1 - four-week block or 2 - two-week blocks.

(Circle) NAME PGY LEVEL 1 2 3 4 5 6

RESIDENCY PROGRAM

REQUEST (Check appropriate) Four-week period Two-week periods

DATES (Prioritize three choices) ROTATION PERIOD(S) ASSIGNED SERVICE 1. 2. 3.

SIGNATURE DATE

APPROVALS 1. PROGRAM DIRECTOR – As Program Director for this resident, I am aware of his/her request for vacation and (please check one) give F do not give F approval to pursue the appropriate approval from the service affected. / / Signature and please print last name Month Day Year

Prior to Approval from the Service Chief, please return this form to ______for processing.

2. SERVICE CHIEF - Based on the review of the schedule, I F APPROVE F NOT APPROVE / / Signature and please print last name Month Day Year

3. CHIEF RESIDENT - I have seen this request and will complete the call schedule accordingly.

/ / Signature and please print last name Month Day Year

FOR OFFICE USE ONLY Date received to process: PGY Mandatory events to attend (ie Residents on Service Level Time Away Request/Dates exams, research day, etc.)