Updated June 2019
TRANSPLANT/HEPATOBILIARY SURGERY – PGY4 & 5 Resident
A. Medical Knowledge
Goal: The resident will achieve a detailed knowledge of the evaluation and treatment of a variety of disease processes in transplant surgery. The resident will be exposed to both medical and surgical emergencies and become comfortable in the initial evaluation and stabilization of such patients.
Objectives: The resident should be able to…
1. Discuss the diagnosis and treatment of organ failure in the following organ systems:
a) kidney
b) liver
c) pancreas
d) cardiac
e) lung
f) small bowel
2. Recite the pathophysiology of end-stage disease in all systems that can be transplanted.
3. Recite the indications and contraindications for transplant surgery by organ systems.
4. Discuss issues in transplant immunobiology for the pre-transplant patient, including:
a) Major histocompatibility complex (MHC)
b) Human leucocyte antigens (HLA)
c) Panel reactive antibody (PRA)
d) Donor specific crossmatch
5. Describe the general medical care of the immunosuppressed transplant patient.
a) Care of routine illnesses in this patient population
b) Common co-morbidities: diabetes, hypertension
c) Health maintenance
6. Discuss the details of pharmacology and pharmacokinetics of the immunosuppressive agents:
a) Steroids
b) Purine analogs and inhibitors
c) Anti-thymocyte preparations
d) Anti-T helper cell drugs (calcineurin inhibitors)
e) IL2 inhibitors
f) Target of rapamycin inhibitors
7. Discuss the details of the specific uses and dosing of immunosuppressive therapy in transplant surgery.
8. Discuss issues in transplant immunobiology for the post-transplant patient, including:
a) Wound healing
b) Basic immune response including antibody recognition of foreign antigens.
c) List the cellular response to foreign tissue or material including the role of lymphocytes, macrophages, and T-cell
d) Graft rejection
i. Hyperacute
ii. Acute cellular
iii. Chronic
e) Infections
i. Bacterial
ii. Fungal
iii. Viral
f) Tumors
i. Skin
ii. PTLD
iii. Others
9. Discuss the diagnosis and treatment of acute and chronic rejection in transplant patients.
a) Differential diagnosis
b) Method of evaluation and diagnosis
c) Treatment rationales
10. Discuss the process of organ donation in the United States.
a) OPTN, UNOS, and CMS
b) Organ availability
c) Donor requirements
B. Patient Care Goals
Goal: The resident will provide care that is compassionate, appropriate, and effective for the transplant surgery patient.
Objectives: The resident should be able to…
1) Participate in the general medical care of immunosuppressed transplant recipients.
2) Interprets laboratory and diagnostic tests as related to pre and post-transplant patients.
3) Direct preoperative assessment, preparation for surgery, and postoperative care of transplant patients in the inpatient and outpatient setting.
a. Discuss the details of the management of wound care in the immunocompromised patient.
4) Make the judgment of placement of vascular access for treatment of ESRD and plasmapheresis.
5) Participate with a high level of surgical independence, in vascular access procedures, including:
a. Vascular grafts for dialysis
b. Peritoneal dialysis catheters
c. Cimino fistulas and other AV fistulas for dialysis
6) Participate with a moderate to high level of surgical independence, in transplant-related surgical procedures, including:
a. Renal transplants
b. Pancreas transplants
c. Small intestine transplants
d. Living organ donor procurement
e. Deceased donor procurement
f. Hepatobiliary procedures
7) Participate, with moderate to high level of independence, in the diagnosis and care of patients with post-operative complications in transplant surgery, including:
a. Delayed graft function
b. Infectious complications
c. Transplant dysfunction and rejection
d. Immunosuppressive drug toxicity
8) Participate, with moderate to high levels of independence, in the treatment of liver failure complications, including:
a. Acute variceal hemorrhage
b. Hepatic encephalopathy
c. Refractory ascites
d. Hepatorenal syndrome
e. Spontaneous bacterial peritonitis
f. Alterations in drug metabolism/excretion
C. Practice Based Learning and Improvement
Goal: The resident will investigate and evaluate his or her own patient care practices, appraise and assimilate scientific evidence, and improve patient care practices.
Objectives: The resident should be able to…
1. Continually re-evaluate personal performance and patient outcomes and seek to improve practice.
2. Recognize the importance of lifelong learning in surgical practice.
3. Provide supervision of junior residents in carrying out patient care responsibilities for the group of patients assigned by the chief resident.
4. Serve as an educator of medical students and junior residents.
5. Participate in local, regional, and national activities, optional conferences, and/or self-assessment programs.
6. Demonstrate the use of a system or process for keeping up with changes in literature and initiates assignments for other learners.
7. Lead surgical skills experiences for students and residents and participates in the development of new curriculum.
D. Interpersonal and Communication Skills
Goal: The resident will demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates.
Objectives: The resident should be able to…
1. Provide an example of effective communication and strong interpersonal skills to junior residents and medical students on the transplant team.
2. Confidently discuss and explain the various etiologies of organ failure, their prognoses and treatment options (surgical and non-surgical), including the risks and benefits.
3. Assume overall leadership of a health care team responsible for his or her patients, while at the same time seeking and valuing input from other team members.
4. Demonstrate willingness and ability to educate junior residents and medical students on the transplant service.
5. Competently manage the transplant service.
6. Serve as a role model and consultant for junior residents.
7. Communicate details of patient progress to the appropriate attending.
8. Negotiate and manage conflict among care providers.
Goal: The resident will 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.
Objectives: The resident should be able to:
Coordinates and directs all aspects of care of the transplant patient, including the initial evaluation, acute management, and long-term rehabilitation.
1. Demonstrate an awareness of and responsiveness to the larger context and systems of health care and the ability to effectively call on system resources to provide care that is of optimal value.
2. Recognizes the surgeon’s role within the larger context of a healthcare system as well as the roles of other healthcare professionals in the overall management of patients.
3. Oversees and assists junior residents in directing the rehabilitation plan and timely discharge/placement of the transplant patient.
4. Coordinate the total care of the transplant patient through established relationships with other healthcare professionals, such as:
a. Social workers
b. Nurse practitioners
c. Physician assistants
d. Dieticians/Nutritionists
e. Physical therapists
f. Occupational therapists.
5. Advocates cost-effective medicine. Limits the use of unnecessary diagnostic tests/studies and educates junior residents and medical students in this practice.
6. Manifests proficiency in the rational use of surgical literature and evidence-based medicine in the management of transplant patients.
7. Possesses knowledge and understanding of risk-benefit analysis and applies this to daily decision-making in current practice.
Goal: The resident will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
Objectives: The resident will be able to:
1. Provide supervision of junior residents in carrying out patient care responsibilities.
2. Consistently demonstrates integrity in all aspects of care and professional relationships.
3. Demonstrates personal and professional responsibility. Positively influences others by assertively modeling professional behavior.
4. Demonstrates leadership skills and interpersonal skills necessary for independent practice as a specialist in surgery.
5. Accepts responsibility for errors in patient care and can initiate corrective action.
6. Serves as a role model for ethical behavior and consistently places the interests of patients ahead of self-interests when appropriate.
7. Understand the concepts of autonomy, beneficence, non-maleficence, justice, and respect for life.
8. Maintain patient confidentiality.