General
Surgery Curriculum 2006 - 2007
CLINICAL
EXPERIENCE
During routine
morning and afternoon rounds
with in-patients faculty and
senior level residents conduct
teaching walk rounds to further
develop medical knowledge and
clinical decision making. Residents
are encouraged to cite and discuss
research publications which may
indicate new approaches and techniques
in the management of surgical
patients. Residents are further
challenged to examine decisions
regarding services, tests and
evaluations which may offer optimal
patient care and cost efficient
healthcare delivery.
GENERAL LINES OF SUPERVISION
The stated
clinical duties and privileges
listed below are broadly stated
and are applied across all
clinics and services.
PGY-1/2:
Is
responsible for the initial physical
examination, collection of historical
data and establishment of a logical
differential diagnosis.
PGY-3:
The
PGY-3, when serving as a senior
resident on the service, is responsible
for the supervision of the PGY-1
and PGY-2, as well as the medical
students assigned to the service.
PGY-4 & 5:
On
some of the services the PGY-4
may assume “chief resident” status
and shares ultimate responsibility
for patient care with the attending
physician. Residents at the PGY-4 & PGY-5
level evaluate patients semi-independently
except on major patient care
matters.
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GENERAL
PRINCIPLES
The
ultimate responsibility for
patient care and clincial
decisions provided by Surgical
Housestaff resides with the
Attending Surgeon.
As outlined in the Joint Statement
on Resident Supervision issued
by the Virginia Commonwealth
University School of Medicine,
the Department of Surgery subscribes
to the philosophy that the most
effective learning environment
for post-graduate medical trainees
is one that allows sufficient
freedom for house staff to share
responsibility for decision making
in patient care, yet provides
adequate faculty supervision
and involvement to provide feedback
to trainees about their actions
and to address the quality and
safety of the care rendered to
patients. Residents will assume
progressive responsibility as
outlined below. Housestaff are
individuals with an M.D., D.O.,
D.D.S., or equivalent degree
who meet the qualifications for
graduate education/training in
the specialties or subspecialties
of surgery or dentistry. In order
to preserve this type of learning
environment for its teaching
program, the Department advocates
the following principles as elements
of its policy on house staff
clinical education and supervision:
1. Housestaff are regarded
as primary physicians for all
patients admitted to the teaching
inpatient services, emergency
rooms and clinics, and, as such,
are responsible for the writing
of orders, for the maintenance
of records and for the execution
of diagnostic, therapeutic and
discharge plans.
2. Depending on their respective
levels of training, it is appropriate
and essential that junior house
staff be supervised by more senior
house staff in accordance with
site-specific guidelines stated
elsewhere in the handbook.
3. All spheres of house staff activity
will be supervised by attending
faculty members who will share
responsibility with house officers
for patient care rendered and who
will have ultimate authority for
final decision making. The nature
and extent of attending physician
involvement will vary according
to site as outlined below.
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SITE-SPECIFIC
HOUSESTAFF SUPERVISION
The structure of house staff-attending
interactions and the form that
faculty supervision of house
staff takes will vary according
to site and type of patient care
setting and is summarized below.
In general, these rules are uniform
for the VCUHS, MCVH, VAMC, and
other affiliated institutions
unless otherwise noted.
Inpatient Teaching
Services
| 1. |
All
patients admitted to the
service will be cared for
by a patient care team
which may include medical
students, interns, residents
and fellows under the direction
of faculty attending physicians. |
| 2. |
Although
decisions regarding diagnostic
tests and therapeutics
may be initiated by the
house staff, these decisions
will be reviewed with the
attending surgeons. |
| 3. |
All
patients will be seen by
the attending and discussed
daily with house staff. |
| 4. |
The
attending will review the
medical record and document
his/her involvement in
the care of the patient. |
| 5. |
All
transfers to another service
and discharges will be
approved by the attending
in advance. |
| 6. |
House
staff are required to notify
the patient’s attending,
in a timely fashion, independent
of the time of day, of
any substantial controversy
regarding patient care,
any serious change in the
patient’s course
including unexpected death,
need for surgery or transfer
to an intensive care unit
or to another service for
treatment of an acute problem,
or for any other significant
change in condition. |
| 7. |
Attendings
or their designee are expected
to be available and responsive,
either by phone or pager,
for house staff consultation,
24 hours a day for their
specific patients unless
other coverage has been
arranged. |
Emergency
Department
| 1. |
Supervision
in the Emergency Department
will be provided 24 hours
a day by Emergency Room
physicians. |
| 2. |
All
patient admissions to the
service will be discussed
with an ER physician or
the appropriate attending
physician unless delay
would result in harm to
the patient. |
| 3. |
All
patient admissions to inpatient
units will be discussed
with the attending (or
his designee) assuming
responsibility, as well
as notifying the resident
team assigned. |
| 4. |
House
staff is responsible for
receiving all referral
calls and for securing
approval for activation
of the MedFlight Helicopter. |
| 5. |
All
patients evaluated by an
intern (PGY-1) will be
presented to a more senior
resident or attending |
Clinics
and Consult Services
| 1. |
A
faculty attending should
be present on clinic site
or in unique circumstances
available by phone. His/her
responsibility will be
the supervision of house
staff working in the clinic. |
| 2. |
All
inpatient consultations
written by a house officer
will be presented to an
attending, countersigned
by that attending, and
amended or supplemented
by the attending as necessary,
in accordance with the
MCVH Consultation Policy. |
Intensive Care Units
House staff
decisions, including senior resident
decisions, regarding admission
and discharge of patients from
the intensive care units, and
regarding the performance of
specified invasive procedures,
may be subject to review by subspecialty
fellows and attendings depending
on the specific procedural rules
for that unit. However, the attending
physicians ultimately are responsible
for all major patient care decisions.
Operating Rooms
| 1. |
The
faculty is responsible
for direct supervision
of all operative cases.
At a minimum, this means
being in the operating
room with the house staff
during critical parts of
the procedure. For less
critical parts of the procedure,
the faculty must be immediately
available for direct participation. |
| 2. |
A
PGY-4 or PGY-5 may act
as a “teaching assistant” on
appropriate cases and supervise
operative procedures performed
by a junior resident, although
the attending surgeon retains
ultimate responsibility
and will be present for
the critical portion of
the surgical procedure. |
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HOUSESTAFF
CLINICAL DUTIES AND PRIVILEGES (CUMULATIVE,
BY YEAR)
| PGY
1 : |
| 1. |
The
PGY-1 is responsible for
primary (initial) performance
of physical examination,
collection of historical
data by house staff and establishment
of a logical differential
diagnosis. |
| 2. |
Responsible
for the initiation of appropriate
diagnostic and therapeutic
orders. |
| 3. |
Recognizes
complications and reports
findings to more senior house
officers or attendings. |
| 4. |
Presents
cases in a concise manner
to a more senior house officer
and/or attending for review
and concurrence with clinical
decisions. |
| 5. |
Reviews
and corrects the “work-up” of
the students assigned to
any patient for whom the
house officer is responsible
and reviews the criticisms
and suggestions with the
student. |
| 6. |
Masters
open and laparoscopic skills
and surgical techniques appropriate
for this level of training
and secures adequate supervision
for those skills not yet
mastered. |
| PGY
2 : |
| 1. |
Formulates
diagnostic and therapeutic
strategies, supervises patient
management, and verifies
accuracy of intern data collection. |
| 2. |
Assumes
primary responsibility for
initiation of appropriate
diagnostic and therapeutic
orders in ICUs. |
| 3. |
Teaches
students and interns and
evaluates their performance. |
| 4. |
Supervises
the performance of procedures
by less senior residents
and medical students until
mastered. |
| 5. |
Notifies
and consults with more senior
house officers and/or attendings
regarding patient status
and major decisions. |
| PGY
3: |
| 1. |
Responsible
for the daily supervision
of interns and/or junior
residents and medical students
when serving as a senior
resident on assigned service. |
| 2. |
Responsible
to conduct inpatient and
emergency room consultations
in a timely fashion and report
findings to the appropriate
attending physician. |
| PGY
4 & 5: |
| 1. |
Shares
ultimate responsibility for
patient care with the attending
physician and works semi-independently
except on major patient care
matters and on operative
procedures. Administrative
responsibilities for operational
matters (e.g., rounds, teaching,
conferences, patient scheduling)
are usually given to this
level. |
| 2. |
On
designated services a PGY-4
may assume “chief resident” status
and associated responsibilities. |
| 3. |
May
not be responsible for the
same patients as a fellow
on the service when serving
as the “chief resident.” |
| PGY
6-8 : |
| 1. |
These
levels almost always represent
customized fellowship training. |
| 2. |
Fellows
function essentially as apprentices
to one or a small group of
attending specialists engaged
in delivery of a usually
narrowly-focused, complex
and demanding form of patient
care. |
| 3. |
Although
fellows may act independently
in the general aspects of
patient care for which they
are fully trained, they work
in subspecialty care under
the supervision of their
mentor(s) at varying levels
of independence according
to the complexity of the
care, their stage of development
and the judgment of their
mentor(s). |
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