About the Department of Surgery

Goals and Objectives

The aims of surgical education in the third and fourth years of our medical school are to:

• Acquire a body of knowledge, skills and attitudes necessary for the recognition and management of patients with diseases that may necessitate evaluation by a surgeon.
• Become familiar with the principles, clinical reasoning, techniques and tools used by surgeons.
• Observe and adopt the attitudes and attributes that promote good patient relations and management. These include, but are not limited to: patient education, emotional support, rehabilitation, and ethical, legal and financial issues.

During the fourth year of medical school, each student will have an additional four weeks of surgical experience which will supplement much of what is learned in the third-year as well as providing a much more "procedure-oriented" experience.

The required experience in surgery has been developed to meet the most recent requirements of the LCME. Though they are designed to provide identical educational opportunities at all the campuses in terms of educational content and modes of evaluation, a variety of clinical experiences are likely to occur at the different hospitals.

Student Objectives

The format of the third-year clerkship provides an eight- week course in the surgical sciences designed to develop knowledge about diseases that may be treated by surgeons. The clerkship permits the student to develop all necessary skills to acquire future knowledge independently and to develop the clinical decision making skills required by all physicians. Acquisition of technical skills is not emphasized; however opportunities for technical development are available in the fourth-year advanced clerkship.

The design of the third- year clerkship shifts emphasis from traditional surgical education including lectures, ward work, and long hours in the operating room unto students assuming a greater role in their self-education. Teaching sessions are case-based, requiring student preparation prior to each session and active participation in the session itself. Faculty members serve as facilitators to help guide the discussion of the cases presented.

Four major educational assumptions provide the foundation for the clerkship experience:

• Learning is a process of active inquiry with the initiative residing in the learner. Therefore, students are expected to function as adult learners as they seek out information and educational opportunities.
• Learning must be a lifelong process stimulated by the desire to provide superior medical care.
• Mastery of the core competencies required in the Clerkships is essential for practice as a competent physician, regardless of career focus.
• Students are expected to demonstrate high levels of competence in applying required knowledge to clinical problem-solving, implementing a reasonable management plan, and displaying the highest degree of professionalism.

Objectives

• Obtain appropriate history and physical exam for patients with symptoms requiring surgical referral
• Develop a differential diagnosis and treatment plan for patients with symptoms that commonly require surgical referral including an understanding and mastery of the basic skills required to order and to interpret commonly used labs and studies
• Demonstrate basic knowledge of strategies to identify, assess, and manage life-threatening surgical emergencies
• Demonstrate basic knowledge of strategies to assess risk, and to prevent, identify and treat post-operative complications
• Demonstrate basic skills in performing routine technical procedures commonly required on a surgical service while demonstrating basic sterile technique
• Recognize appropriate consultation resources, both medical and non-medical, and demonstrate an awareness of available community resources
• Demonstrate basic knowledge of altered structure and function (pathology and pathophysiology) of the body and its major organ systems that are seen in various surgical diseases
• Demonstrate the basic knowledge required to assess and treat pain, and ameliorating suffering
• Recognize the importance of cost- effective health care, quality assurance, and practice guidelines in today's health care market
• Observe and adopt the attitudes and attributes that promote effective patient and professional relationships, including honesty, integrity, and compassion.
• Demonstrate effective communication with patients, patient's families and colleagues

Organization of Third Year Clerkship

Rotation Schedule - New Brunswick Campus

Students complete six weeks of general surgery / vascular surgery.

Rotations occur at one of three sites: Robert Wood Johnson University Hospital in New Brunswick, Jersey Shore Medical Center in Neptune, or The Medical Center at Princeton in Princeton.

The remaining two weeks consist of an elective chosen from a list of available opportunities. Students will receive exposure in orthopaedic surgery and urologic surgery via outpatient experiences distributed throughout the third year clerkship. Students may utilize the two-week elective to obtain additional exposure to orthopaedic or urologic surgery.

A list of index cases with which the student should have some clinical experience will be provided. Attendance at clinical rotations is mandatory. Unexcused absences may result in a grade of Fail or Conditional Pass (please see Final Clerkship Grades below).

Faculty Preceptors and Tutors

Students will be assigned to a faculty preceptor who will oversee the students' activities throughout the eight-week clerkship. For each specific rotation (e.g. general surgery, vascular surgery, elective) the student will be assigned a faculty tutor(s) who will be the student's guide for that portion of the clerkship. The preceptor will facilitate surgical education throughout the clerkship to assure an adequate breadth and depth of clinical experience. The tutor will be the student's primary contact for day-to-day clinical activities. The preceptor and tutor will guide the student in constructing a daily schedule and discuss the student's current cases. The faculty will assist in the choice and preparation of the student's required case presentation and provide frequent feedback to the student about his/her progress in meeting the goals of the clerkship.

Preceptor responsibilities include:

• Coordinate student participation throughout the eight-week clerkship to assure a breadth of clinical exposure.
• Oversee the student's patient care activities (review written H&P's, discuss patient management of the student's assigned patients, etc.)
• Conduct weekly clinical sessions with the group of students, possibly as teaching rounds.
• Individual student meetings to review clinical activity (patient contact log) and overall progress (provide feedback).

Students will participate in the resident services as appropriate and available, and at a level commensurate with their experience and abilities, assist in direct patient care. Students will participate in resident /service rounds as appropriate for the educational goals of the clerkship. Students are encouraged to see and participate in the surgical management of cases even when they are being managed by an attending other than their tutor or preceptor. When reasonable, they may also cross over to other teams or services. Participation in an index case should be arranged by contacting the appropriate resident on the team concerned and clearing it with the tutor.

The student should meet with their tutor and preceptor on the first or second day of each rotation to establish learning objectives, determine the weekly meeting times (group and individual), and establish outpatient and operating room commitments. During the weekly individual meetings, the preceptor will review and critique the student's written H & P, and discuss the student's activity log.

The preceptor will not have primary responsibility for grading the students, but will have input into the grading process (see Final Clerkship Grades below). Students are encouraged to elicit specific feedback about their performance from their tutor and preceptor.

Weekly Written History and Physical

Each week (except for Weeks 1 and 8), the student is required to complete at least one H&P, for a total of 6 per rotation. The H&P should be actually performed by the student, written up, and submitted to the preceptor. The format for the H&P is a focused history and physical examination, a differential diagnosis, a brief discussion of the pathophysiology of the case, and a treatment plan with a rationale for the treatments selected. The tutor or another faculty member may review the H&P. It remains the student's responsibility to present the previously reviewed H&P to their preceptor for inclusion in the evaluation packet.

Weekly Case-based Didactic Sessions

A case-based framework is used to present didactic information. The topics for presentation are derived from a national consensus on competencies that should be mastered by students during their Surgery Clerkship. The 4th Edition of the Manual of Surgical Objectives will be the basis for all didactic sessions, including the teaching cases. The emphasis of the didactic session is to be on discussing the clinical case(s). Each session is intended to address clinical reasoning that crosses traditional discipline lines and focuses on developing a differential diagnosis and treatment plan. Student participation is to be active discussion, not passive attention solely to lectures. The case-based sessions will be facilitated by faculty and will cover essential information that is assessed on the final examinations. There may be assigned readings that students are expected to complete prior to the case-based sessions. Student attendance and participation during the case-based discussions is required for successful completion of the clerkship.

Student Case Presentations

Each student will prepare and present two cases. The purpose of the student case presentations is to give students the opportunity to give a focused case presentation followed by a cogent discussion of the point of interest. The presentation and discussion time will be limited. Therefore, the student should plan to limit his/her presentation to permit an interactive format without compromising their presentation. The topic should be on some interesting aspect of a case in which the student participated. The content of the case presentations should contribute to the students' basic knowledge of surgical disease and patient management, while emphasizing the aspect of the case that was intriguing to the presenter.

OSCE's (Objective Structured Clinical Examinations)

The students will complete OSCEs to assess their overall clinical reasoning and discrete, focused clinical skills. The final OSCE will be graded.

On Call

Students will be expected to be "on-call" a minimum of six nights during the rotation. Call is to be taken in-house and to begin with evening sign-out rounds and to end after morning sign-out rounds. Students must contact the senior resident covering their service to determine the time and place to report.

Clerkship Grades and Materials

The Surgery Department Clerkship Committee will determine the student's final grade. This committee will review the student's performance on all components of the clerkship. The final grade will reflect the student's overall and cumulative performance including all evaluations of clinical performance, grand rounds presentations, OSCE score, written examination score, the patient contact log, H&P's, participation in didactic sessions, and other required components of the clerkship.

The scale for final course grades is in accordance with the policy of the University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School and consists of five levels: Honors, High Pass, Pass, Conditional Pass and Fail.

A grade of Fail or Conditional Pass for one component may result in a course grade of Conditional Pass. After the student remediates a final course grade of Conditional Pass, the highest remediated course grade that can be awarded is a Pass. Receiving multiple Conditional Pass evaluations or one or more Fail evaluations may result in a final grade of Fail. This grade will become part of the student's official records. Remediation of a final course grade of Fail is possible in accordance with the Academic Rules and Regulations of the UMDNJ and RWJMS. However, once the student remediates a final grade of Fail, the student will receive a grade no higher than Pass for the course.

At a minimum, candidates for a final grade of High Pass will demonstrate above average performance in all aspects of the clerkship, including clinical rotation evaluations, student grand rounds, the final OSCE, and the NBME written examination. For the OSCE and NBME examinations "above average" is defined as "above the mean" and "above the 50th percentile" respectively. Candidates for a final grade of Honors are expected to consistently perform at a superior level in all aspects of the clerkship (clinical rotation evaluations, student grand rounds, the final OSCE, and the NBME written examination). For the OSCE and NBME examinations "superior" is defined as "at or above one standard deviation over the mean" and "at or above the 80th percentile" respectively. In addition to the final grade, the clerkship director will forward 'summative comments' on the student's performance for use in the Dean's letter. These will be based upon the written comments from the faculty. Extenuating circumstances can always occur and will be taken into consideration by the faculty grading committee when appropriate. However, these must be made apparent immediately to the clerkship director or the director of education and will not be considered after the fact.

Recommended Text

Learning Surgery, Stephen F. Lowry Editor, 10th edition, Lange Medical Books.

Surgery Clerkship Competencies

The competencies listed below will be derived from the ASE Manual of Objectives which covers 29 frequently encountered signs and symptoms of surgical disease.

Overview

The clerkship is the culmination of the required experience in Surgery, providing the student with the opportunity to apply the knowledge learned in the third year and gain additional experience in the direct clinical management of acutely ill surgical patients in a longitudinal fashion from presentation to discharge. This clerkship is focused on the "acute" patient from the emergency room to the intensive care unit. The student will actively participate on a surgical team working with faculty and other care providers. The educational experience will include supervised clinical experiences, didactic lectures, case based learning and self-study.

Goals

• To master the required skills necessary to evaluate patients with surgical disease.
• To develop skills needed to care for the "acute" patient.
• To introduce to the student the function and responsibility of house officers involved in the care of surgical patients.
• Demonstrate the attitudes and attributes that promote good patient relations and management. These include but are not limited to patient education, emotional support, rehabilitation, and ethical, legal and financial issues.

Objectives

Master the initial evaluation of an acutely ill patient

• Understand the pathophysiology and clinical manifestations of shock, specific operative stresses, and injuries (including brain injury, spinal cord injury and pulmonary injury).
• Learn the philosophy, priorities, and techniques of initial resuscitation and evaluation of patients with injury, operative stress, and shock.
• Demonstrate your knowledge in patient care by recognizing, treating, and preventing complications of injury and shock.

Gain experience in a surgical environment performing invasive diagnostic and therapeutic procedures

• Practice all infection control and universal precaution procedures.

Develop higher level function in the management of the peri-operative and intensive care unit patients

• Participate in ICU and General Floor care.
• Understand the pathophysiology and clinical manifestations of pulmonary, renal, nutritional, and multisystem organ failure.
• Implement plans of treatment of patients in shock, acute trauma patients and post-operative patients in the ICU and acute care floors.
• Perform emergency and daily physical examination on critically ill patients and prepare progress notes in ICU and acute care floors, under supervision.
• Understand the basic principles and commonly used modes of mechanical ventilation and be able to prescribe ventilator settings.
• Understand the principles, indications, limitations, and physiology of invasive monitoring techniques (e.g. arterial & central venous catheters, pulmonary artery catheters, intracranial pressure monitors) and be able to interpret the information obtained.
• Understand the principles of surgical nutrition, monitoring, assessment of needs, and be able to write a prescription for total parenteral nutrition and supplemental enteral feedings.
• Understand the pathophysiology and management of head injury.
• Respect patient confidentiality.
• Work with ancillary personnel (nurses, lab techs, x-ray techs, etc.) in a collaborative fashion.

Grading

The students have daily dialogs with the faculty. They receive frequent formative feedback during the rotation. They receive summative feedback from the faculty. Clinical experience logs are reviewed. The mechanism for determination of students’ final grades is identical at all sites. The surgery department clerkship committee determines each student’s final grade. This committee reviews the student’s performance on all components of the clerkship. The final grade reflects the student’s overall and cumulative clinical evaluations, clinical examination performance, and performance on an oral presentation. The final grade is determined by weighting the clinical grade assigned by faculty (60%), the final examination (20%) and the oral case presentation (20%).

The scale for final course grades is in accordance with the Academic Rules and Regulations 23rd edition UMDNJ - RWJMS and consists of five levels: Honors, High Pass, Pass, Conditional Pass, and Fail. A grade of Fail or Conditional Pass for one component may result in a course grade of Conditional Pass. After the student remediates a final course grade of Conditional Pass, the highest remediated course grade that can be awarded is a Pass. Receiving multiple Conditional Pass evaluations or one or more Fail evaluations may result in a final grade of Fail. This grade will become part of the student’s official records. Remediation of a final course grade of Fail is possible in accordance with the Academic Rules and Regulations 23rd edition RWJMS. However, once the student remediates a final grade of Fail, the student will receive a grade no higher than Pass for the course. Extenuating circumstances can always occur and are taken into consideration by the faculty grading committee when appropriate. However, these must be made apparent immediately to the clerkship director, co-director, or the director of surgical education and are not being considered after the fact.

Clinical Sites

Currently, the Advanced Clerkship in Surgery is offered a Robert Wood Johnson University Hospital and Jersey Shore Medical Center. At Jersey Shore Medical Center, students work directly with the trauma-critical care faculty on a combined service for the entire block.