THE CORE COMPETENCIES IN GENERAL SURGERY
The Accreditation Council for Graduate Medical Education (ACGME), including the Residency Review Committee (RRC) for surgery, has adopted a set of general competencies for all physicians who complete higher training programs. These have been adapted for each specialty. In the near future, all chief residents must be assessed as competent in these areas prior to receiving certification for completion of residency training and undertaking the American Board of Surgery examinations. The six general competencies are:

Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Surgical residents are expected to critically evaluate and demonstrate knowledge of pertinent scientific information.

Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. Surgical residents are expected to critique personal practice outcomes and demonstrate recognition of the importance of lifelong learning in surgical practice.

Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. Surgical residents are expected to communicate effectively with other health care professionals, counsel and educate patients and families, and effectively document practice activities.

Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Surgical residents are expected to maintain high standards of ethical behavior, demonstrate a commitment to continuity of patient care, and demonstrate sensitivity to age, gender and culture of patients and other health care professionals.

Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Surgical residents are expected to practice high quality, cost effective patient care, demonstrate a knowledge of risk-benefit analysis, and demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management.

EDUCATIONAL GOALS OF THE GENERAL SURGERY TRAINING PROGRAM
The major educational goal of the General Surgery Residency Training Program in the Department of Surgery at the University of Louisville is to produce a board certified surgeon capable of independently practicing general surgery of highest quality.  On completion of the program, the surgeon should have a general knowledge, clinical judgment, the basic technical skills and personality attributes to establish rapport with patients and their families for the practice of general surgery, and be assessed as competent in the six general areas as outlined under the core competencies.  These attributes will be acquired over at least a five-year training period by acquiring new knowledge through clinical experiences, reading current literature and major textbooks, attending bedside rounds and conferences, and preparing reports for presentation and publication.  Knowledge of the clinical course of patient disease will be acquired by managing surgical patients both as in- and outpatients, including management of the critically ill surgical patient.  Most importantly, technical skill to perform operations and intra-operative decision-making will be acquired through observation and performance of a variety of surgical procedures within the realm of general surgery over the training period.  The residents will record each operation performed or assisted, in an ongoing fashion, thereby preparing an operative log of case experience.  This operative log will be entered directly onto the web-site provided by the RRC for Surgery.  Each resident is responsible for his/her own resident data collection for the duration of his/her residency.  The ability to convey the clinical course of given patients will be developed by case presentations during walk rounds and conferences.  The ability to interact appropriately with referring physicians and consulting physicians will be acquired by periodic communication with such physicians throughout the training period.

During the PGY-1 year the resident will become familiar with the fundamentals of management and pre- and post-operative care of the general, cardiothoracic, pediatric, and transplant surgical patient.  This goal will be achieved by performance of initial patient assessment including history and physical and interpretation of routine laboratory tests and imaging studies.  Additionally, assistance with or performance of certain operations will be carried out.  The PGY-1 resident will also acquire knowledge of post-operative patient care by daily assessment of in-hospital post-operative patients on the floor and, as needed, in the Intensive Care Unit.  Further knowledge of post-operative care will be learned by attending clinics and management of the patient in an ambulatory setting.  Technical skills including basic instrument techniques, suturing, and retracting shall also be learned during the PG-1 year.  It is our goal that residents will act as surgeon for some basic cases with proper supervision.

During the PGY-2 year the resident will further enhance his/her skills of peri-operative and operative management by performing additional and more complex operations. These trainees have a primary role in the Intensive Care Unit at most of the major integrated and affiliated hospitals and should be facile with all invasive procedures relevant to ICU care.  Skills in surgical specialty services not acquired in the PG-1 year will be done in this year.  PGY-2 residents will be responsible for presentation of patients during walk rounds at the VAMC and University Hospital unless otherwise directed by the chief resident on the service. 

During the PGY-3 year, initial patient assessment skills will be honed by seeing the majority of consultations on the Emergency Surgical Service at University Hospital, as well as the General Surgical Services at the VAMC.  The PGY-3 resident will acquire a full range of technical skills regarding intestinal surgery, laparotomy for trauma, and major resuscitation of the trauma patient.  The PGY-3 resident should have met all of the goals for the surgical specialties listed with the exception of the senior rotation in Pediatric Surgery.   

The PGY-4 resident should acquire the knowledge, skill and personal attributes to be chief resident of the major private services at Norton, Kosair Children's and Jewish Hospitals.  The PGY-4 shall assign junior residents specific patients to follow in hospital, as well as specific patients to be attended to in the operating room.  The PGY-4 resident will routinely communicate with the attending to discuss pre-operative and post-operative patient care and mutually participate in critical decision making.  These residents should be able to perform most complicated operations by the end of this year.

The overall educational goal for the PGY-5 year is to prepare the chief resident to assume independent responsibility for total care of the surgical patient.  This will be accomplished by assigning the chief resident primarily to the VA and University Hospitals throughout the PG-5 year, where he or she will be the team leader of the particular rotation.  The chief residents will be responsible for supervising all in-hospital patient care and for supervising outpatient care in the clinics.  The chief resident will be responsible for preparing the morbidity and mortality reports presented at the Quality Improvement Conference pertaining to their own patients, as well as determining the autopsy status on each death and the status of the transplanted organs from those patients; the latter will be done in conjunction with the transplant coordinator.  The chief resident will become familiar with quality assurance issues by having a seat on the Quality Assurance Committee at University Hospital.  The chief resident will develop clinical decision-making skills by interacting directly with the attending surgeon for critically ill patients and those undergoing operation.  The chief resident will supervise and assist the junior residents in critical patient care, as well as in performing certain operations.

EDUCATIONAL GOALS FOR SPECIFIC ROTATIONS AND PGY LEVEL

(Residents at all PGY levels will be expected to supervise and teach both 3^rd and 4^th year medical students assigned to their respective services.)

GENERAL SURGERY SERVICE AT UofL HOSPITAL

To become competent in the management of surgical diseases in largely indigent patient population who are prone to obesity, malnutrition, diabetes, end stage renal disease, and late stage cancer.  This will be accomplished in large part by an initial outpatient visit and formulation of a differential diagnosis, followed by appropriate laboratory and imagining workup, and finally by an elective operation and subsequent post-operative care.  The general surgery residents will assume primary management of these patients. 

PGY-1:  To begin the path to competency in the six general areas, by performing daily patient assessments documented by patient histories and physicals, daily notes, discharge summaries, by making decisions regarding patient management appropriate for the PGY-1 level on elective general surgery patients, and by attending all relevant conferences, teaching and daily bedside rounds.  This will also include performance of procedures as outlined in the supervisory lines of duty in the ambulatory setting, at the bedside, and in the operating room as appropriate for the PGY-1 level.  Interaction with the attending surgeon as appropriate. To become familiar with suturing techniques, routine perioperative care, including specific diseases such as inguinal hernia, breast, and gallbladder disease.  

PGY-2:  To continue the path to competency in the six general areas, by performing daily patient assessments documented by patient histories and physicals, daily notes, discharge summaries, by making decisions regarding patient management appropriate for the PGY-2 level on elective general surgery patients, including the intensive care units, and by attending  all relevant conferences, teaching and daily bedside rounds.  This will also include performance of procedures as outlined in the supervisory lines of duty in the ambulatory setting, at the bedside, and in the operating room as appropriate for the PGY-2 level.  Supervision of PGY-1 level residents, and interaction with the attending surgeon as appropriate.  To become familiar with the critical care management of complex elective surgical patients and management of post-operative complications which require intensive care including ventilator management.

PGY-3:  To continue the path to competency in the six general areas, by performing daily patient assessments documented by patient histories and physicals, daily notes, discharge summaries, by making decisions regarding patient management appropriate for the PGY-3 level on elective general surgery patients, including the intensive care units, and by attending all relevant conferences, teaching and daily bedside rounds.  This will also include performance of procedures as outlined in the supervisory lines of duty in the ambulatory setting, at the bedside, and in the operating room as appropriate for the PGY-3 level.   Supervision of PGY-1 and 2 level residents, and interaction with the attending surgeon as appropriate.  To become competent in the operative management of routine elective cases such as cholecystectomy, colectomy, mastectomy, and in the pre-operative decision making such as whether and when to recommend operations to patients for their disease states.  To become competent in the outpatient management, workup of routine elective surgical patients, and alternative therapies such as medical management and interventional catheter based techniques.

PGY-4:  To continue the path to competency in the six general areas, by performing daily patient assessments documented by patient histories and physicals, daily notes, by making decisions regarding patient management appropriate for the PGY-4 level on elective general surgery patients, including the intensive care units, and by attending all relevant conferences, teaching and daily bedside rounds.  This will also include performance of procedures as outlined in the supervisory lines of duty in the ambulatory setting, at the bedside, and in the operating room as appropriate for the PGY- 4 level.   Supervision of PGY-1, 2 and 3 level residents, and interaction with the attending surgeon as appropriate.  The PGY-4 will serve as chief of the private elective patients and become competent in the management of both routine and complex elective surgical patients.  The PGY-4 will supervise junior residents in the operating room as well and serve as surgeon junior or first assistant to the attending on complex elective cases such as whipple, esophagogastrectomy, major vascular procedures, and proctocolectomy.

PGY-5 (Chief Resident):  To continue and eventually complete the path to competency in the six general areas, by performing daily patient assessments documented by patient histories and physicals, daily notes, by making decisions regarding patient management appropriate for the PGY-5 level on elective general surgery patients, including the intensive care units, and by attending all relevant conferences, teaching and daily bedside rounds.  This will also include performance of procedures as outlined in the supervisory lines of duty in the ambulatory setting, at the bedside, and in the operating room as appropriate for the PGY-5 level.   Supervision of PGY-1, 2, 3 and 4 level residents as appropriate.  The chief resident will supervise the daily activities of the service and be in contact with the attending surgeon as appropriate.  The chief resident will serve as teaching assistant to junior residents on routine elective cases appropriate for the junior residents experience.

EMERGENCY GENERAL SURGERY, TRAUMA, AND  BURNS AT UofL HOSPITAL

 To become competent in the management of acutely injured or ill patients who will require urgent operations and critical care.  This will be accomplished primarily by initial consultation through emergency room physician referral and involve resuscitation, workup algorithms, prioritization, operation, and peri-operative critical care.  Competence in directing multi-specialty management of critically ill surgical patients will be achieved by developing a close working relationship with physicians in many different specialties. The general surgery resident will assume primary responsibility for patient management under direction of faculty surgeons with an interest in trauma and critical care. 

PGY-1: Residents will interact with emergency general surgery patients, trauma and burn victims.  This patient population will consist of patients requiring acute surgical care such as those with peritonitis, skin and soft tissue infections, blunt and penetrating trauma, and burns.  Evaluation of the injured patient, basic principles of resuscitation, and principles of recovery from burns and injury through managing patients on the floor and in follow-up clinics

PGY-2:  Residents will interact with emergency general surgery patients, trauma and burn victims primarily in the ICU and burn unit.  These residents have primary direct responsibility for these patients.  To become competent in the nutritional management of these patients including access such as central line and PEG placement.

PGY-3:  The PGY-3 residents serve as the initial consulting resident for non-life threatening consultation in the ER and from other services within the hospital.  The PGY-3 resident and chief residents respond to all Level I trauma alerts.  The PGY-3 resident should be able to develop a treatment plan and triage multiple injury patients.  They perform many surgical procedures with chief residents/attendings supervision.

PGY-4:  There are no PGY-4 residents on this service.

PGY-5 (Chief Resident):  The chief resident supervises all of the activities of the service and works directly with the PGY-3 triage resident.  He/she responds to all Level I trauma alerts with 15 minutes.  He/she consults with attending surgeons on al all aspects of the service.                                

GENERAL SURGERY AT VETERANS AFFAIRS MEDICAL CENTER

To become competent in the management of veteran patients with surgical diseases and multiple co-morbidities such as heart disease, peripheral vascular disease, cancer, and chronic lung disease in this predominantly elderly male patient population.  This will be achieved by both an in patient and outpatient experience in management, by participation in several specialty clinics with diagnostic workup, medical clearance, surgery scheduling, operation and post-operative care.  The residents will achieve competency in clinical management by mastering risk assessment in this group of challenging patients by thorough understanding of co-morbid medical illness.

PGY-1:  PGY-1 residents are expected to assess all admissions to the service and to develop rudimentary treatment plans for a variety of surgical patients.  The PGY-1 should learn fundamentals of pre and post-operative care.  Participates as surgeon on basic operations and assists on other cases.  The resident should attend outpatient clinic two days per week under supervision of the chief resident.

PGY-2:  The PGY-2 residents do most of the direct ICU care.  They participate in the OR with many basic cases and work in the clinics two days per week.  They also gain valuable non-cardiac thoracic experience working with the attending, Dr. Wrightston, on this service.  To become familiar with thoracic surgical disease and the operative and perioperative care of these patients.

PGY-3:  The PGY-3 resident does many of the more complex operations and works with specialty services such as urology, ENT/Head and Neck when general surgery consultation is needed.  They present at Tumor Board.

PGY-4:  There are no residents at this level on the service.   

PGY-5 (Chief Resident):  The chief resident oversees the service in consultation with the attendings.  He/she will perform most of the advanced operations and is primarily responsible for the care of the large number of vascular surgery patients. 

GENERAL AND VASCULAR SURGERY AT NORTON HOSPITAL

To become competent in the management of tertiary general surgical, surgical oncologic, and vascular patients through direction by faculty.  The residents will also become competent in minimally invasive and catheter-based surgical techniques by close faculty supervision and extensive clinical experience.  Competence in peri-operative management will be achieved by initial daily patient visits and close communication with faculty in the clinical decision making on this group of patients with complex surgical disease. 

PGY-1:  These residents will interact with both elective and emergency general surgical patients at Norton Hospital.  They will become familiar with the perioperative care of these patients and will serve as first responders to queries by the nursing staff and thereby gain expertise in this area. This patient population will consist of patients requiring acute and elective surgical care such as those with peritonitis, skin and soft tissue infections, cancer, vascular disease, diabetes, and hernias.  The population of patients also consists of tertiary referrals with complex general, thoracic, and oncologic problems cared for by the full-time faculty.  Residents will also interact with internists in private practice to gain experience in interpersonal communications with such referring physicians.  To become familiar with appropriate interpretation of the surgical literature by participation in weekly journal club.

PGY-2:  Similar for PGY-1 goals and additionally these residents will become familiar with perioperative critical care of complex tertiary.  They will understand critical care by cardiologists and pulmonologists and become competent in the nutritional management of these patients including the prescribing on TPN.  They will assist attending in the OR on more complex cases and thereby move along the pathway to competency in the operative management of both routine and complex elective surgical patients.  Residents will also interact with internists in private practice to gain experience in interpersonal communications with such referring physicians. To become familiar with appropriate interpretation of the surgical literature by participation in weekly journal club.

PGY-3:  The PGY-3 will interact with both elective and emergency general surgical patients at Norton Hospital and become competent in the overall management of routine elective cases.  Residents will also interact with internists in private practice to gain experience in interpersonal communications with such referring physicians. To become familiar with appropriate interpretation of the surgical literature by participation in weekly journal club. 

PGY-4:  The PGY-4 will serve as either the chief or assistant chief of the service.  He/she will be familiar with most all of the patients on the service and communicate directly with the attending in most cases.  The chief will supervise the junior residents and assign patients to them.  The PGY-4 will also interact closely with the nurse practitioner, and be surgeon junior for most of the surgical cases.  The chief will also directly interact with many other specialists including pulmonary, cardiology, radiology, and primary care physicians. To become familiar with appropriate interpretation of the surgical literature by participation in weekly journal club.

VASCULAR SURGERY AT NORTON HOSPITAL

PGY-3, 4, and 5:  The goals are similar for all three resident levels on this rotation. The residents will become competent in the total management of the patient with vascular disease including catheter based and open surgical techniques.  They will be responsible for all patients under the care of the two vascular surgeons.  This will include direct communication with the attending on a daily or more frequent basis as needed, and making daily rounds on all of these patients.  The resident will serve as surgeon junior or first assistant to the attending depending on case complexity and resident experience.

CAST ROTATION AT NORTON HOSPITAL

PGY-4 and 5:   The goals are similar for both resident levels.  These residents will become familiar with advanced surgical techniques such as minimally invasive procedures, interventional radiologic procedures, and endoscopy of the biliary tree.  They will participate in the pre-operative work-up, surgical procedures, and post-procedure care of these patients.  These will be separate cases from those that the other residents at Norton are caring for. To become familiar with appropriate interpretation of the surgical literature by participation in weekly journal club

GENERAL AND VASCULAR SURGERY AT JEWISH HOSPITAL

To become competent in the management of broad based general surgery.  The residents will also become competent in the management of vascular and general thoracic patients by working closely with faculty and their private patients. 

PGY-1:  These residents will become competent in the peri-operative management of routine general surgical cases seen at Jewish Hospital.  PGY-1 will also assist in the operating room and serve as surgeon junior on simple cases.

PGY-2:  The goals are similar to those for the PGY-1 level, but the PGY-2 will participate in the critical care of surgical patients and gain expertise by interacting with other specialists in the ICU management of these patients.  Residents will also interact with surgeons in private practice to gain experience in this type of practice setting.  PGY-2 will begin to become competent in the surgical management of routine cases.

PGY-3:   These residents will participate in the management of more complex patients including serving as surgeon junior or first assistant to the attending, and supervising the critical care management of these patients.

PGY-4: The PGY-4 will serve as chief of the service.  He/she will be familiar with most all of the patients on the service and communicate directly with the attending in most cases.  The chief will supervise the junior residents and assign patients to them.  The chief will also directly interact with many other specialists including pulmonary, cardiology, radiology, and primary care physicians.

PGY-5 (chief resident): The PGY-5 will also serve as chief of the service, as there is not a 4 and 5 on this service simultaneously.  He/she will be familiar with most all of the patients on the service and communicate directly with the attending in most cases.  The chief will supervise the junior residents and assign patients to them.  The chief will also directly interact with many other specialists including pulmonary, cardiology, radiology, and primary care physicians.

VASCULAR SURGERY AT JEWISH HOSPITAL

PGY-3 and 4: The goals are similar for all three levels on this rotation. The residents will become competent in the total management of the patient with vascular disease including catheter based and open surgical techniques.  They will be responsible for all patients under the care of the two vascular surgeons.  This will include direct communication with the attending on a daily or more frequent basis as needed, and making daily rounds on all of these patients.  The resident will serve as surgeon junior or first assistant to the attending depending on case complexity and resident experience.

TRANSPLANT SURGERY AT JEWISH HOSPITAL

To become competent in the management of transplant patients and be familiar with the associated disease spectrum seen in this unique patient population.  The residents will become familiar with clinical management of immunosuppressive agents in conjunction with specialty physicians. 

 PGY-1: As outlined above for PGY-1 level residents, but residents will interact with both elective and emergency transplant surgical patients at Jewish Hospital.  This patient population will consist of patients requiring kidney, liver, and pancreas transplants, organ harvest and dialysis access procedures.  Experience will also be gained in the acute and elective general surgical care of transplant patients.  Residents will also interact with the transplant team and become familiar with routine immunosuppressive medication used in the care of such patients.  The basics of immunosupression should be learned. 

 PGY-4: The PGY-4 resident will function as a chief resident on this service.  They will act as surgeon with supervision on appropriate transplant cases including renal transplantation and will serve as first assistant on hepatic transplant procedures. 

PEDIATRIC SURGERY AT KOSAIR-CHILDRENS HOSPITAL

To become competent in the management of pediatric surgical patients and develop skills necessary to professionally relate to parents and families of these children. 

PGY-1: To begin to become competent in the management of pediatric surgical patients by performing history and physical examinations on all new admissions and develop a treatment plan.  They will then present to their chief resident.  They will learn to perform appropriate bedside procedures on children.  The PGY-1 will participate in basic surgical procedures.  They will attend the pediatric surgery conference and thereby gain knowledge in this field and present cases and discussions of disease states as well.

PGY-2: The PGY-2 resident will function essentially as the PGY-1 resident does, but will perform slightly more complex operations. 

PGY-3:  The PGY-3 level residents will interact with both elective and emergency general surgical patients at Kosair-Childrens Hospital. This patient population will consist of patients requiring acute and elective surgical care such as those with pediatric disorders, peritonitis, skin and soft tissue infections, cancer, burns, trauma, and hernias.  Residents will also interact with pediatricians, neonatologists, critical care and emergency medicine pediatricians, and residents in pediatrics to understand the special needs of children with surgical illness and of their parents. They will serve as surgeon junior or first assistant to the attending depending on the complexity of the case and resident experience.  They will attend the pediatric surgery conference and thereby gain knowledge in this field and present cases and discussions of disease states as well. 

PGY-4: The PGY-4 resident will act as the chief resident on this service.  He/she will supervise the service and ensure a treatment plan is developed for each patient with the attending.  They will become competent in the management of most surgical diseases of children by becoming familiar with all patients on the service. They will attend the pediatric surgery conference and thereby gain knowledge in this field and present cases and discussions of disease states as well.

COMMUNITY GENERAL SURGERY

To develop competence in the management of the broad spectrum of general surgical patients including those undergoing minimal access surgery in a community private setting. 

PGY-3 and 4:  The goals are similar for both resident levels.  This rotation is designed to accomplish several fundamental goals.  It will allow residents an opportunity to participate in a busy private practice rotation in a suburban community hospital.  They will have the opportunity to do a number of “bread and butter” cases and will be familiarized with practice management styles that differ from indigent and teaching care locations of clinical and full-time faculty.

RURAL SURGERY ROTATION

To become familiar with surgical patient disease seen in the rural setting.  Residents will become familiar with the kinds of patients and family interactions seen in both the clinic and hospital in a rural community and its referral base.

PGY-2 or PGY-3:  The goals are similar for both resident levels.  The rural rotation is located in Madisonville, KY about 130 miles from Louisville.  The hospital is divided by a large multi-speciality clinic.  Residents will be exposed to patients with different health issues and will have the opportunity to provide high quality surgical care in an alternative rural environment.  This rotation offers one-on-one mentoring with broad-based general surgeons who care for a variety of surgical problems. 

ENDOSCOPY

On this rotation residents will become familiar with routine upper and lower endoscopy including EGD, colonoscopy, PEG, and able to perform these procedures with minimal supervision independently.

PGY-4 or 5: The residents will achieve at least the minimum number of cases as required by the RRC.  These will include interventions such as biopsy, polypectomy, and cessation of bleeding.  The resident will become competent in the decision of whether and when to perform these procedures.  ERCP is an option on this rotation.