SURU-4003 - Acting Internship in General Surgery

SURU-4003 - Acting Internship in General Surgery

Elective Title: Acting Internship in General Surgery
Course Number: SURU-4003
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 3
Prerequisites: Successful completion of Year 2
Additional Requirements: Successful completion of Surgery Clerkship. (Period 1 is a max of 6 students)
Responsible Faculty Director: Sarah Samreen, MD Periods Offered: 1-13 including holiday period 8 
Coordinator: Amy White Other Faculty: Alexander Perez, MD; Marilyn Marx, MD; Richard Lu, MD; Douglas Tyler, MD; V. Klimberg, MD; J. Walker,MD; Uma Phatak, MD; Pamela Daher, MD; Colleen Silva, MD; Michael Norman, MD
Location to Report on First Day:
Surgery Student Coordinator, Amy White, 6.132 McCullough

1. To expand clinical skills in caring for general surgery patients in clinic and in-patient settings, including H&Ps, problem-focused assessments of post-operative patients with normal and complicated post-operative events, verbal and written communication of patient status (i.e. H&P/SOAP notes, presentation on rounds), incorporation of evidence into clinical decision-making and management of patients throughout the course of workup and treatment.
2. To increase the volume of patients on a service for which the student can maintain knowledge and understanding of presentation, workup, treatment and pertinent clinical events, to the level required as a house officer.
3. To improve and expand upon technical skills.

1. Demonstrate proficiency at information-gathering through communication with healthcare providers, the medical record, history, physical exam, and ordering/interpreting diagnostic tests.
2. Demonstrate the ability to use clinical information to formulate assessments and plans for patients in the clinic and in-patient setting, and accurately communicate clinical information to patients, families, surgical team members, and other healthcare providers.
3. Demonstrate the ability to write initial admission orders, transfer orders, routine in-patient orders, and discharge orders.
4. Demonstrate the ability to perform a safe, accurate and concise hand-off of the patients on the service to a covering provider.
5. Demonstrate proficiency at suturing, knot-tying, fundamentals of laparoscopic surgery, fundamentals of endoscopy, and simulated gastro-intestinal anastomosis.

Description of course activities
Within limits set by law and hospital rules, will function with the same responsibilities and duties as an intern or first year house officer. Students will have same hours and call responsibilities as an intern and will be in attendance on Wednesdays at 0700 for Grand Rounds and Morbidity and Mortality conference in Room 6.106 McCullough.
Students will function as a member of one of the adult general surgery teams and are expected to follow patients in the intensive care units and make daily reports on rounds regarding their condition. Such reports are expected to include an assessment of the patients condition with recommendations for further evaluation or changes in therapy based on that assessment. All students are expected to assist in the operating room and attend all outpatient clinics. Students will be assigned at least two and no more than four overnight calls during the one-month rotation. Students will be expected to see inpatient consults and present to residents and faculty.
Students will participate in technical skills training through the Laboratory for Surgical Training, Assessment and Research (LSTAR), and be expected to practice to proficiency in suturing/knot-tying, fundamentals of laparoscopic surgery, basic endoscopy, and GI anastomosis.

Type of students who would benefit from the course
This course will be especially useful for those students planning careers in surgery in general, General and Thoracic Surgery specifically, Intensive Medicine and Anesthesiology.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday (outpatient clinics) 8:00 5:00
Tuesday (OR) 7:15 5:00
Wednesday (OR) 9:00 5:00
Thursday (OR) 7:15 5:00
Friday (clinic) 8:00 5:00
Saturday (Rounds) 7:00 12:00
Sunday (Rounds) Off

 Average number of patients seen per week: 20
 Call Schedule: On average, 2 in-house calls per 4-week period.

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    Daily, with an initial assessment in LSTAR, and a final assessment in LSTAR.
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    Faculty and Residents
  B. Frequency / Duration of Presentation(s)?
  C. Format - What guidelines are set for the student's presentation?
    SOAP format
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Weekly H&Ps on at least 2 patients, daily notes on at least 3 patients, and a 1-page write-up of a case, synthesizing medical literature to analyze workup and treatment plan, as well as potential complications
  B. Format - What guidelines are set for the student's written work?
    Same as used by physicians. H&P that includes history of presenting illness, past medical history, medications, past surgical history, family history, social history, assessment, and plan. Progress notes in SOAP format.
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
    at least one article from a pubmed search, and other additional sources are acceptable - textbooks, up to date, etc.
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    related to a case the student scrubbed
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Students are to participate in those conferences and activities that the surgical team to which they are assigned participate. Students will present their case report and literature review to the general surgery team during teaching rounds.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Clinical evaluation by faculty; technical skills assessment in LSTAR; oral exam

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    Students will be given a booklet to document the feedback they have sought out from residents and faculty; they will meet weekly with course director and have a discussion of this feedback, as well as review the students written notes and discuss patients, which will also allow for feedback on fund of knowledge relating to these patients, and feedback on verbal communication skills.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
Laparoscopy (simulation lab and OR)
Endoscopy (simulation lab, and OR/GI lab)
gastro-intestinal anastomosis (simulation lab)
order-entry in EPIC (simulation lab for now)

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    Central line placement (simulation lab)
robotic surgery (simulation lab)

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    Similar - the AI will be expected to know the clinical status of all patients on the service, including the plan discussed at rounds, follow-up on results from tests, interpretation of results of diagnostic studies, and to communicate results to the team in an appropriate time frame. The student will be expected to recognize when to escalate care or when information needs to be urgently communicated to the resident or faculty.
Differ - the student will not be able to enter orders in the EMR on active patients.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    The student will have an opportunity to function as an intern, to experience a more rigorous set of clinical demands, and be supported as he/she develops the knowledge, behaviors and attitudes to successfully care for surgical patients as part of a resident team.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    The student will present on rounds daily with residents and faculty. These presentations will include a synthesized assessment and plan. Student will receive immediate feedback from residents and faculty. The course director will meet with the student once at midpoint to also provide formal feedback.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    There are 4-5 faculty on each general surgery team; the AI should endeavor to attend clinic with each faculty at least once during the rotation and scrub cases with each faculty. The student should see faculty 2-3 times per week.

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    There will be 3 or 4 different faculty working with the student and providing direct supervision over the duration of the course. The residents working with the student will be those on service ranging from intern to chief. Students can obtain letters of recommendation from any of these faculty. Feedback will be solicited from faculty and residents at mid-point and then again at the end of the course. It will be communicated to the student by the course director.