Colorectal Surgery Resident Manual

RESIDENT SUPERVISION AND CHAIN OF COMMUNICATION

AMBULATORY CARE

The resident is required to attend two half days of outpatient Colorectal Surgery clinic per week. The CRS resident will interview the patient initially. Performance of the physical exam will depend on the complexity of the problem and may be deferred until the attending is present, especially in the early months of the CRS resident’s experience. The key points of the exam are either performed with both the CRS resident and attending present, or confirmed by the attending if performed earlier by the CRS resident. The CRS resident is expected to review ancillary studies as available, including labs, imaging, etc. The CRS resident then presents the case to the attending and discusses differential diagnosis and appropriate therapy choices. The resident and attending return to the patient and key points of history or exam are confirmed by the attending as needed. The resident and attending discuss with the patient the diagnosis and choices for further evaluation or therapy.

As the resident gains experience with the complex cases seen by the Colorectal Surgery attendings, it will be expected that s/he will complete the clinic evaluation, review ancillary studies, and present the case to the attending, discussing differential diagnosis and treatment options. The attending may confirm key portions of the history and physical exam. The resident and attending will discuss diagnosis and therapy options, and will then advise the patient of the diagnosis and treatment options. Dictation of the clinic note may be done by the resident at the attending’s discretion. If the resident dictates the clinic report, the attending reviews and modifies it if needed prior to its finalization. Immediate formative feedback is given to the resident following all clinic sessions, and after the attending surgeon reviews the dictated clinic report.

Anorectal physiology evaluation and endorectal/endoanal ultrasounds are performed in the outpatient clinics. Patients are scheduled specifically for these procedures, usually after their initial clinic evaluation. It is expected that the Colorectal Surgery resident will arrange to participate in anorectal physiology testing sessions once per month, and in ultrasound evaluations as often as possible.

ENDOSCOPY EXPERIENCE

The resident will spend one to two half-days per week gaining experience in flexible and rigid endoscopy. Each of the Colorectal Surgery attendings has block time in the outpatient endoscopy unit(s). The resident will be responsible for arranging to spend time in the endoscopy suite, being mindful that index operative cases will take priority over outpatient endoscopy. Endorectal/endoanal ultrasounds are often performed in the endoscopy suite as well.

HOSPITAL CARE

Operative procedures: It is the policy of the Department of Surgery that an attending surgeon participate in all operative procedures performed, as well as supervise the other aspects of patient care. In appropriate circumstances the Colorectal Surgery resident will benefit from the experience of assuming responsibilities for independently executing surgical procedures. The following conditions must always apply:

• Every patient undergoing an operative procedure must have an assigned attending surgeon identified by name in the medical record.
• Only the responsible attending surgeon may empower the resident to proceed with an operative procedure in the attending’s absence. The attending surgeon must remain available to respond in a timely fashion should assistance be requested by the resident. The attending surgeon must personally perform or direct all key portions of the procedure.
• Operating room personnel may at anytime request verification of the attending’s permission to proceed. Concerns regarding the appropriateness of that decision or the subsequent execution of the procedure are to be discussed with the attending surgeon, the Section Chief, or the Department Head.

The CRS resident will be given increasing responsibility in the operating room.  The resident may be directed to dictate the operative report, which the attending reviews and modifies if needed prior to its finalization. Immediate formative feedback is given to the resident following all surgical procedures, and after the attending surgeon reviews the dictated operative report.

The resident is expected to enter all operative and endoscopic

Hospital care: The resident is given graded responsibility for care of inpatients, realizing that the resident is a PGY-6. Attending supervision occurs daily. The resident is expected to see all admissions and document findings in a note or dictation. Attendings must be notified of admissions within 60 minutes of being seen by the resident. Attendings must see the patient and confirm the resident’s findings and plan within 24 hours of admission, and sooner if indicated. Any discordance regarding diagnosis and/or therapy plan are discussed to enhance the learning experience. The resident sees all hospitalized patients daily and documents progress and daily plan in the chart. Attendings use the inpatients for teaching opportunities, and round daily with the residents for both teaching and management.

Consults/ED patients: The resident must notify the responsible attending within 60 minutes of seeing a consult to discuss the consult with the attending and present a plan of management. The resident is expected to dictate the consultation report, which the attending reviews and modifies if needed prior to its finalization. Immediate formative feedback is given to the resident following all consultations, and after the attending surgeon reviews the dictated consultation report. Attendings see each admitted consult within 24 hours of admission, and sooner if indicated. Attendings see ED consults with the resident as indicated.

CHAIN OF COMMUNICATION

The resident will have access to pager numbers for all Colorectal Surgery attendings, and will be apprised of the attendings’ call schedule as well. In the event that an attending surgeon cannot be contacted within a reasonable time period, the resident is directed to call or page the Program Director. In the event that the Program Director is out of town or otherwise unavailable, another of the attending Colorectal surgeons will be identified as the emergency contact person.

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