latest 19 may 2014

General Surgery Curriculum

FF5126 Module Head :Dr (Ms). Saladina Jaszle Binti Jasmin

Assistant: Dr (Mr).Azlanuddin bin Azman

I.INTRODUCTION

During the 7 week posting, the students will initially be given a week of refresher course which will includeseminars andlectureson specific topics plus demonstrations

on basic surgical procedures (Appendix 1). Following this, they will bedivided into 2 groups; each group will be required to spend a 3 week rotation each in UKMMC and TelukIntan Hospital (Appendix 2). The group at UKMMC will be further divided

based on the 5 units in General surgery consisting of ;

1. Breast and Endocrine Surgery 2. Colorectal Surgery 3. Hepatobiliary Surgery

4. Vascular Surgery 5. Minimally Invasive Surgery

These subgroups will consist of 5-15 students who will be taught by 5-10 lecturers. Each lecturer is required to teach at least weekly for a minimum of an hour.

However,the leaders of these subgroups are responsible to contact the lecturers

themselves, early in the posting, to arrange for these teaching sessions which are usually conducted in the wards. Other additional teaching sessions usually take place

in the operation theatres, clinics and endoscopy suites. Students are exposed to the concept of senior clerkship during their surgical attachment. The senior clerkship

serves to prepare the students to become familiar and competent in handling common surgical cases and perform simple day-to-day procedures as surgical house officers.The current module will give more emphasis in basic surgical emergencies

and procedures. Apart from these, the general surgical posting also impartsthe personal and professional development module in the training. In line with the senior

clerkship concept, the students are required to go on-call and perform as “Junior House Officers”.

All tasks(performed/observed) by the students must be immediately documented in their respective log books(Appendix 3) for verification/grading purposes by the

supervising doctors/staff. At the end of each 3 week posting, the students need to get their supervisors’ report. Each student should at the end of the surgical posting have a total of 2 supervisor’s report; one from Teluk Intan Hospital and one from UKMMC.

The Friday of the 5th week of posting is the dateline to submit a case report to the

office for stamping of date of reception; those submitted thereafter will be rejected & the student will be given a zero for his/her case write-up. The end of posting test will be held in the surgical wards in UKMMC on the last day.Having completed the

surgical posting, the students are expected to have acquired the necessary surgical knowledge and skills to enable them to be proficient house officers.

Year5 UKMMC General Surgery 2012/13

TelukIntan Hospital

Teaching Faculty :-

1) Mr Lewellyn Rajakumar-General Surgeon 2) Mr Mohan Gopalakrishnan – General Surgeon 3) UKM Lecturer from the Surgical Department – One lecturer per week for 2 sessions (1-2hours/session)

Guidelines and Role of Resident Teaching Faculty:

1. Each doctor is required to spend a minimum of four hours of student teaching/supervision per week. 2. Students should be supervised in history taking, physical examination and

management of patients. Procedures that are stated in the log book (Appendix 3) should be supervised/demonstrated to them.

3. Student presentations in the clinics, ward rounds and bedside teaching sessions should be documented by the students in their respective log books. 4. Besides presentations, students are required to record all tasks performed, assisted

or observed immediately in the log book ; these will need endorsement/grading by the supervising doctor/staff.

5. Doctors are required to complete the supervisor’s report (Appendix 4) and hand to The office in UKMMC in a sealed envelope to be given to the student group leader on their last day in Teluk Intan.

He/she will need to return these to the Surgical Department in UKMMC on the same/next working day.

6. Doctors here are most welcomed to provide feedback/contact theYear 5 Module head/Assistant on any relevant issues.

The student leader will need to liase with EncikMarzuki or PuanKhairunnisaat the

Undergraduate Office at UKMMC, in regards to:

1. Thesupply of gloves, aprons, hats & masks

2. Transport between UKMMC &TelukIntan Hospital


III. MODULE LEARNING OUTCOMES

General :

At the end of year V, the students should be able to:

1. Assistas a junior doctor in the surgical wards under direct supervision of a medical officer.

2. Apply basic surgical knowledge and skills effectively, to practice safely and competently.

3. Participate as a team member and assume leadership role in relevant situations.

4. Conduct basic surgical procedures in the wardunder direct supervision of a

medical officer/ staff, as deemed appropriate. 5. Commit to lifelong learning.

Specific Learning Outcomes :

At the end of the 7-week attachment, the student should be able to:

1. Satisfactory obtain a surgical history and perform physical examination.

2. Request basic and specific investigations to assist in diagnosis and management of common surgical problems.

3. Interpret relevant findings to reach a correct diagnosis. 4. Understand and discuss appropriate management of common surgical diseases.

5. Discuss the principles of surgical practice in the management of surgical patients.

6. Understand the ethical and medico-legal issues in the management of surgical patients. 7. Perform simple ward procedures competently. (e.g: phlebotomy, bladder

catheterization, blood taking, setting up an intravenous drip) 8. Assist in simple surgical procedures (e.g: insertion of chest tube, excision of

lumps, toilet and suturing) 9.Participate in the collaborative management involving allied healthcare personnel (e.g: pharmacist, nutritionist, physiotherapist, rehabilitationist,

and social services available) in the management of surgical patients. 10.Understandskills in dealing with uncertainty, death and dying patients.

11.Demonstrate a sense of responsibility in interpersonal and professional conduct.


IV. COURSE CONTENT

A. Clinical Topics

General Surgery

( must know)

General Surgery

( should know)

General Surgery

( nice to know )

Trauma - ABC of trauma - primary survey

- secondary survey - types of shock &

management - types of trauma &principle management

- chest injury - head injury: types &

management - genitourinary trauma

Endocrine

-benign thyroid diseases -thyroid malignancies -thyrotoxicosis

-hypercalcaemia and hypocalcaemia

Endocrine

-complications of thyroid surgery&management -primary and secondary

hyperparathyroidism -Cushing’s syndrome

-Conn’s syndrome -phaechromocytoma

Endocrine

-carcinoidtumour -insulinoma -adrenocortical carcinoma

-anteriormediastinal mass -inflammatory thyroid

diseases

Breast - benign diseases

- malignancies - nipple discharge

Breast -ductal carcinoma in situ

-lobular carcinoma in situ -phyllodestumour

-Paget’s disease -chronic granulomatous mastitis

Breast -reconstruction: types &

indications -management of non

palpablelesions

General

- hernia :inguinal, ventral, femoral, incisional,

paraumbilical& complications - lumpsand bumps;

management - appendicitis

General

- types and management of enterocutaneous

fistulaes

Upper GI

-peptic ulcer disease -gastric carcinoma -oesophageal carcinoma

-reflux

Upper GI

-Barrett’s oesophagus -oesophageal corrosive injuries

-gastric lymphoma

Upper GI

-hiatus hernia


-achalasia

-haemorrhage& acute management

-gastric outlet obstruction

Hepatobiliary

- surgical jaundice - benign biliary duct disease

- malignant biliary duct disease - hepatictumours

- pancreatitis - pancreatic carcinoma

Hepatobiliary

-imaging modalities for investigation of diseases

-chronic liver disease -portal hypertension

Hepatobilliary

-hepaticencephalopathy -hepatolithiasis

Colorectal

-haemorrhage&acute management

- acute intestinal obstruction - carcinoma - diverticular disease

- haemorrhoids - fistulae in ano

-ischiorectal abscess - principle of stomas

Colorectal

-Famillialadenomatous polyp

-sigmoid volvulus -inflammatory bowel disease

-tuberculosis -anal fissure

-anal carcinoma

Colorectal

-rectal prolapse -anal sphincter injury

-chronic constipation -radiationproctitis -ischaemic colitis

Vascular -acute& chronic limb

ischaemia -varicose veins

-chronic venous insufficiency -thrombosis -abdominal aortic aneurysm

Vascular - access and chemo-port

management -trauma

- mycotic aneurysms

Vascular - vasculitides

- upper limb ischaemia

Paediatric Surgery

-bilious vomiting in neonates -acute abdomen in infants

-surgical jaundice in infants -solid organ injury in children -inguino-scrotal swelling in

children -intestinal obstruction

Paediatric Surgery

-common abdominal tumours in children


Urology

-haematuria: causes & management -benign prostatic hyperplasia

-genitourinary calculi -management of testicular

pain

Urology

-management of testicular swelling -Fournier’s Gangrene

Urology

-prostate carcinoma

Plastic Surgery -benign and malignant skin lesions

-benign and malignant oral lesions

-burns& management

Plastic Surgery - parotidtumours

Neurosurgery - brain abscess

Neurosurgery -braintumours

-spinal cord compression -hydrocephalus

B.Clinical procedures

To perform under supervision To observe

-venous blood taking -intravenous drip -insertion/removal of venofix

-blood culture & sensitivity -insertion/removal of urinary catheter

-insertion/removal of nasogastric tube -removal of sutures -wound dressing

-digital per rectal examination -proctoscopy (+/- enema insertion)

-taking informed consent -arterial blood gas -fine needle aspiration cytology ( FNAC)

-core-biopsy -insertion of Sengstaken- Blakemoore tube

-suprapubic catherisation -insertion/removal of chest tube -insertion of central venous line

-banding of haemorrhoids -incision and drainage

-stoma care -endoscopy (OGDS/ERCP/colonoscopy/sigmoidoscopy)


V. TEACHING-LEARNING METHODOLOGY

A. Workshop , Lectures &Seminarsin the 1st week

1)A workshop will include briefing and demonstrations on -basic clinical procedures

-asepsis / sterility -handling of basic surgical instruments 2)Seminar& Lectures on core surgical topics

-will be facilitated by designated lecturers

B. Clinical Teaching Rounds Students are expected to attend ward roundseveryday according to their respective teams. They are expected to perform as junior house officer and participate in the

team’s patient care. They are expected to present the cases during the ward rounds.

C. Wardwork

Students are expected to work together with the house officers and medical officers after the clinical teaching rounds. Apart from tagging in the wards, students are also

expected to go to the outpatient clinics, operating theatres and endoscopy suites to clerk patients and to observe procedures.

Whilst in the ward, the students are also expected to observethe work of the allied health providers and provide assistancein the day to day running of the ward (ie; Dietician, Pharmacist, Physiotherapist, etc.) in the co-management of surgical

patients.

D. Bed side teaching The students are expected to arrange the bed side teaching with their respective lecturers/doctors.During these teaching sessions, the students may discuss problem-

based learning, patient management, case presentations or perform clinical examination under supervision.

E. On-calls Students will be allocated on-call duty according to their respective teams, generally

once alternate week. They are expected to tag along the Medical Officer On-call for that particular day as “junior House officer”. They are required to attend to patients at

the Emergency Department, operating theatre, endoscopy suites and the wards. Students are expected to present the cases to the respective Medical officer/ Registrar / Lecturer.

On Call Duties: 1.On-Call will be at UKMMC andTelukIntanHospital from 5pm to 12 midnight

followed bya normal day the following day. 2.On-Call duties must be emphasized parallel as the concept of junior clerkship.

Patients must be seen first-hand together with the house-officer on call, clerked, taken blood investigations and managed accordingly until reviewed by the medical officer/ specialist.

3. Blood investigations will be taken by the student under the supervision of the house officer/ medical officer.

4. All surgical procedures that are required of the Year V students will be under the supervision of the medical officer/specialist.


5. If a particular student is unable to do the call, he or she has to find a replacement for that particular day. 6. At any day, these cases could be asked to be presented and discussed in the group

bedside teaching by the supervisor.

F. Operation Theatre Students are encouraged to “Scrub up “ and assist as a second assistant in both the main and day care operation theatres.

G. Continuous Medical Education (CME) activities Students will be introduced to the concept of lifelong learning and are expected to

participate in the department’s regular CMEs ie; Journal Club Presentation, Recap (Revision of clinical case management and presentation), Radiological conferences, Histopathological conferences, Surgical updates, Surgical research

presentations(Surgitract), and Mortality & Morbidity meetings.

H. Clinical Proficiency Test ,CPT At the end of each posting there will be a formal assessment by the lectures. Each student will be given 20 minutes to examine/discuss a patient. The student will be

tested for another 10 minutes on an instrument and/or radiograph.

VI. ABSENCE FROM POSTING ACTIVITIES/SCHEDULE

The students are required to attend all academic and clinical activities pertaining to their course module. The attendance is 100%. If a student is unwell and is absent, a

medical certificate (m.c.) of illnessmust be produced to the respective lecturer on his/her return.

If a student is unable to attend a session due to involvement in any official extra-curricular activities, an official letter stating his/her involvement must be produced to

the respective lecturer on his/her return. The m.c.or letter, whichever may be the case, then needs to be given to the surgical

department office for recording/filing.

VII. ASSESSMENT

Areas of Assessment Percentage

i. Clinical Proficiency test - 50% ii. Supervisor’s reports(2) - 20% iii. Log Book - 20%

iv. Case report - 10% Total 100%

A student will need to acquire a minimum50% ofthetotal marksto be considered to

have passed the surgical posting/module.


VIII. REFERENCES

A. Textbooks:

1. Forrest, Carter, Macleod: Principles and Practice of surgery. Churchill

Livingstone, Latest Edition (2005). 2. Cushieri, Hennessy,Greenhalgh, Rowley and Grace; Clinical surgery.

Blackwell science, Latest Edition (2003). 3. Williamson; Scott: An Aid to clinical Surgery. Churchill Livingstone, Latest

Edition (2005).

4. Norman L Browse; An introduction to the Symptoms and Signs of Surgical Diseases. Latest Edition (2005).

B. Reference books:

1. Cushieri, Giles, Moossa; Essential Surgical Practice, Latest Edition(1996). 2. Bailey and Love’s Short Practice of Surgery, Latest Edition (2004).

C. Web:

1. Surgical tutor- surgical-tutor.org.uk 2. International journal of surgery - http://www. theijs.com

UPDATED: March 2012- Dept. of Surgery Year 5 Curriculum Committee

a. Mr. Hairol Othman b. Mr Azlanuddin b. Azman c. Mr. Noor Izham Ismail d. Ms Marjmin bt. Osman

1st Revision on the Updated Year 5 Curriculum, March 2012 - Dr Saladina Jaszle @ 28th April 2014

http://www/


APPENDIX 2: WEEKLY TIME-TABLE/ DEPARTMENT ACTIVITY A. UKMMC

Monday Tuesday Wednesday Thursday Friday

7.30am-8am CWR

8am – 9am Surgitract Recap

CPC Radiology

conference

Census/ HPE

conference/ Surgitract

9am – 10am CWR

10am – 1pm Wardwork/Clinic/OT/Endoscopy

2pm- 3pm CWR

3pm- 5pm Bedside teaching (based on respective lecturer)

5pm-12

midnight On-Call; Once alternate week

B. TELUK INTAN HOSPITAL

Monday Tuesday Wednesday Thursday Friday

8am – 10am CWR

GWR

9am-12am 10am – 1pm Wardwork/Clinic/OT/Endoscopy

2pm- 3pm Wardwork

3pm- 5pm Bedside teaching (based on respective doctor); 4 hrs/week/per doctor&

3hrs/week/UKMMC lecturer

5pm-12

midnight On-Call; Once alternate week

Abbreviation & Venue: CWR Clinical Ward Rounds GWR Grand Ward Round CPC Clinico-pathological conference ;Auditorium HPE conference Histopathologicalexamination conference , last

Friday of the month ; Pathology seminar room Recap Revision of clinical patient management SurgitractSurgical research presentations Radiology conference Radiology seminar room


WEEKLY TIME TABLE

Week 1: UKMMC

CME/ CPC ( 1 hr)

Demonstration/Lecture Seminar

Ward Work/ Bedside teaching

On call

Mon Dept CME (1 hr)

Briefing (1 hr)

Surg L1 (2 hrs) Demonstration (2 hrs)

Rad L1 (1 hr)

Tues Recap (1 hr) Surg L2 (2 hrs) SurgL3(1 ½ hrs)

SurgL4(1 ½ hrs) SurgL5(1 ½ hrs)

Wed CPC (1 hr) SurgL6(1 ½ hrs) Sem 1 (2 hrs) Rad L2 (1 hr)

Sem 2 (1 ½ hrs)

Thurs Radiology conf (1 hr) Sem 3 (1 ½ hrs)

SurgL7(1 ½hrs) Sem 4 (2 hrs) Rad L3 (I hr)

Fri Census/HPE/Surgitract (1 hr)

Sem 5(1 ½hrs) Sem 6(1 ½hrs)

Total 6 hrs 6 + 6.5 + 6 + 6 + 3= 27.5 hrs

Week 2-4: UKMMC

CME

Clinic/OT/Endoscopy Ward Work

Bedside Teaching

On call

Mon Dept CME (1 hr) 12 hrs/w eek

2 hrs 1.5 hr

3.5 hrs/w eek (Alternate

w eek on call X1 ie 7 hrs per

call)

Tues Recap (1 hr) 2 hrs 1.5 hr

Wed CPC (1 hr) 2 hrs 1.5 hr

Thurs Radiology conf (1 hr) 2 hrs 1.5hr

Fri Census/HPE/Surgitract (1 hr)

2 hrs 1.5 hr

Per Week 5 hrs 12 hrs 10 hrs 7.5 hrs 3.5 hrs

Week 5-7: TelukIntan Hospital

CME/Others

Clinic/OT/Endoscopy Ward Work/

Bedside Teaching

On call

Mon 12 hrs/w eek

15 hrs/w eek

4 hrs/doctor/

w eek

3hrs/lecturer/w eek

3.5 hrs/w eek

(Alternate

w eek on call X1 ie 7 hrs per

call)

Tues

Wed

Thurs Last Thurs: Return Trip (2-5pm)

Fri GWR (3 hrs) Last Fri: Exam in

UKMMC (9am-1pm)

Per Week 3 hrs 12 hours 15hrs 15 hrs 3.5 hrs

L: Lecture Sem: Seminar Surg: Surgical Rad:Radiology


CREDIT HOURS

PROGRAMME UKMMC TELUK INTAN HOSPITAL

GRAND TOTAL

CME 21 6 27.0

Lecture/seminar 27.5 0 27.5

Bedside Teaching 22.5 45 67.5

On call 21

21.0

Case report 1x 6 hrs 6 0 6.0

OT/Clinic/Endoscopy 36 33 69.0

Ward work 30 41 71.0

TOTAL 155hrs 125 hrs 280hrs


APPENDIX 3

Year V Log Book (FF5126)

Department of Surgery

Name:

Matric No. :

Session:

Group :

Posting date Begin : End :

Supervisor(s) :

1. 2.


Lecturer(s) in charge :

1. 2.

Clinician(s) in charge :

Registrar: 1. 2.

Medical Officer: 1. 2.

House Officer: 1. 2.


Procedures performed

No. Type Date Diagnosis Supervisor’s Name

Signature

1 Insertion of a venofix

( 5 cases)

2 Removal of a venofix

( 5 cases)

3 Insertion of a

nasogastric tube

( 3 cases)


4 Removal of a

nasogastric tube

( 3 cases)

5 Insertion of a urinary

catheter (2 cases)

6 Removal of aurinary catheter (2 cases)

7 Wound dressing

(3 cases)

8 Removal of sutures/

R.O.S

(3 cases)


9 Venepuncture

( 5 cases)

10 Digital rectal examination

& proctoscopy

( 3 cases)

11 Setting up an intravenous drip

( 3 cases)

12 Blood culture & sensitivity (3 cases)


Procedures observed

No. Type Date Diagnosis Supervisor’s name

Signature

1 Arterial blood gas

/puncture

2 Insertion of a central venous line

3 Insertion of a chest tube

4 Removal of a chest

tube

5 Insertion of an enema

6 Core biopsy

7 Fine needle aspiration cytology

8 Rubber banding of

piles

9 Suprapubic

catheterization

10 Stoma care

11 Taking an informed

consent

12 Toilet & suturing


Endoscopic observations

No. Type Date Diagnosis Supervisors’s name

Signature

1 OGDS

2

Colonoscopy

3 ERCP


On call duty

No. Type of Procedure

Date Diagnosis Supervisor’s Name

Signature


Case Presentation

a) Clinic No. Patient’s name RN Date Diagnosis Supervisor’s

name Signature Marks

Pass: 5-10

Fail: 0-4

1

2

3

4

5


b) Ward round

No. Patient’s name RN Date Diagnosis Supervisor’s name

Signature Marks Pass: 5-10 Fail: 0-4

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

C) Bedside Teaching


No. Patient’s name RN Date Diagnosis Supervisor’s name

Signature Marks Pass: 5-10 Fail: 0-4

1

2

3

4

5

6

7

8

9

10

Operation Theatre:

Students are encouraged to “Scrub up “ and assist as a second assistant.


a)Main / General

No. Patient’s Name

RN Date Diagnosis Type of Surgery Surgeon’s Name

Signature

1

2

3

4

5

b) Daycare

No. Patient’s RN Date Diagnosis Type of Surgeon’s Signature


Name Surgery Name

1

2

3

4

5

LOG BOOK ASSESSMENT


No. Type Poor <40%

Satisfactory 40-75%

Excellent >75%

1 Procedures

performed

0

1

2

2 Procedures

observed

0

1

2

3 Endoscopics

observed

0

1

2

4 On call

0

1

2

5 Clinic presentations

0

1

2

6 Ward round presentations

0

1

3

7 Bedside teaching

presentations

0

1

3

8 Main OT 0

1

2

9 Day care OT

0

1

2

TOTAL (20%)

Assessor’s Signature:

Name/Stamp:

Date:

APPENDIX 4: SUPERVISOR’S REPORT


Name : Matric No. : Year : Date of Posting:

Clinical Assessment

Component Excellent (5) Good ( 4) Fair (3) Borderline(2) Fail ( 1)

1 History

2 Examination

3 Diagnostic skill

4 Investigation

5 Management

6 Clinical knowledge

Professional Assessment

Component Excellent (5) Good ( 4) Fair (3) Borderline (2) Fail ( 1)

7 Appearance

8 Bedside manners

9 Attitude

10 Attendance TOTAL SCORE

Total final score ( Clinical + Professional Assessment score ) = /50

Comment :

______________________________________________________________________________

_______________________________________________________________________

-------------------------------------------

Date: Supervisor’s Signature & Stamp

APPENDIX 5:CLINICAL PROFICIENCY TEST


Student Name: Matric No.:

Examiner 1: Examiner 2:

CASE 1 (Modified Long / Short Case)

Diagnosis:

Component Assessed

__________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________

Marks: /10

Lecturer’s Comment:

_____________________________________________________________________________________________

_____________________________________________________________________________

CASE 2 (Instrument / Radiograph)

Diagnosis:

Component Assessed

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Marks: /10

Lecturer’s Comment:

__________________________________________________________________________________________________________________________________________________________________________

__________________ ___________________

Signature & StampSignature & Stamp

Date:

latest 19 may 2014

Health & Medicine