The Department of Surgery's General Surgery Residency Training Program at the Alpert Medical School, Brown University, is a five year training program accredited by the Accreditation Council for Graduate Medical Education (ACGME), and approved by the Surgical Residency Review Committee for 35 categorical positions and 10 preliminary positions. There are twenty-nine additional resident trainees who also rotate within our program. Residents from Plastic Surgery (6), Orthopaedic Surgery (6), Neurosurgery (1), Urology (2), Anesthesia (2) and Emergency Medicine (12) rotate on general surgery rotations and spend anywhere from one month to nine months training in our Program to meet their home program's ACGME specialty required surgical training. The following document will review our curriculum, our methods of assessment, some special features of our program and our outcomes.
Our surgical training program provides a comprehensive education in basic science and core clinical knowledge. It provides cognitive, technical, communication, professionalism and leadership skills required to excel as a surgeon. All surgical residents receive extensive training in preoperative evaluation in the clinic and hospital settings, intraoperative technique, postoperative, critical care management, and follow up care. Residents rotate through several unique hospitals, allowing for diversity, breadth and depth of training. In these training settings, the surgical residents are taught, supervised and evaluated by surgical faculty. Operative and non operative patient care training is provided with appropriate levels of supervision by faculty members to promote progressive autonomy of trainees that is consistent with Institutional Policies. Supervising faculty promote progressive autonomy of trainees that is consistent with Institional Policies. Supervising faculty members assess the knowledge and skills of each resident and delegate to him or her appropriate level of patient care authority and responsibility. Assessment of residents in patient care is guided by specific national standards-based criteria, including milestone designated for general surgery.
In order to prepare residents for the practice of general surgery, or the related surgical subspecialties, we continually re-evaluate and
enhance our educational program. The surgical training program has cultivated a robust educational experience for residents not only in the basic science and clinical knowledge as applied to practice of surgery, but also across all the core competencies required by the Accreditation Council for Graduate Medical Education: Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems Based Practice.
Our program has followed the web based SCORE curriculum since 2007. Created by The Surgical Council on Resident Education (SCORE), a non-profit consortium formed by the principle organizations involved in U.S. surgical education (American Board of Surgery, American College of Surgeons, American Surgical Association, Association of Program Directors in Surgery, Association for Surgical Education, Residency Review Committee for Surgery, ACGME, Society of American Gastrointestinal and Endoscopic Surgeons). The SCORE curriculum contains patient care topics organized into twenty-eight organ system-based categories which are built-in into a curriculum for a five year general surgery training program. Topics cover not only the knowledge related to specific disease and operations, but also knowledge of systems and conditions that affect the body as a whole. The Department of Surgery supports both the Training Program's membership and individual resident membership for access to the SCORE portal. The SCORE portal is used for the delivery of the educational content and assessment in support of the curriculum to our trainees Learning modules are available on the web via the portal, each module features learning objectives, study questions and a variety of resource materials, including textbook chapters, videos, and radiologic images. SCORE learning modules also provide quizzes with multiple choice questions for use in assessing resident knowledge.
All new interns in our general surgery program participate in a Surgical Objective Structures Clinical Examination (OSCE) session. The OSCE has been instrumental in providing interns with the basic skills, knowledge and confidence desired before they begin their clinical schedule. During the OSCE, new interns are educated and evaluated on basic patient management such as the evaluation and management of post-operative complications and the evaluation and management of critically ill patients, either immediately post operatively or in the intensive care unit. The interns are also evaluated on procedural competencies such as advanced venous access procedures, tube thoracostomy, and bedside debridement. The OSCE also ensures the Program's compliance with the ACGME requirement which states the Program Director must define and demonstrate competencies with a definitive metric for direct and indirect supervision of patient management and procedural competencies.
Our PGY 1 Boot Camp Series are faculty lead, in-depth one-two hour teaching sessions. Occurring twice per week over an approximately ten week period, sessions are focused on patient management and procedural competencies. Some examples of session topics are surgical nutrition, ventilator management, and ultrasound guided line placement. During Boot Camp, interns are tested and provided with feedback of their performance.
Incorporation of select simulation training modules, courses and programs continues to complement our curriculum.
All surgical residents participate in the Advanced Trauma Life Support® (ATLS®) program. Simulating a variety of trauma scenarios, this program teaches residents a systematic, concise approach to the care of a trauma patient. It provides a safe and reliable method for immediate management of injured patients, how to assess a patient’s condition, resuscitate and stabilize him or her, and determine if his or her needs exceed a facility’s capacity. It also addresses how to arrange for a patient’s inter-hospital transfer and assure that optimum care is provided throughout the process.
A Compartment Syndrome Training Module has been added to improve the junior resident's surgical ability to identify and manage compartment syndrome clinically. Following a short multiple choice pre test, residents attend an interactive lecture on compartment syndrome. This is followed by a hands-on workshop to demonstrate proficiency in identifying the location of lower leg compartments and the proper technique of intracompartmental pressure monitor use. Immediately after the module workshop, residents take a short multiple choice test, and have an additional similar test one month later to measure retention of knowledge.
Fundamentals in Laparoscopic Training(FLS) is provided to all residents and a dedicated practice and testing space has been created for resident use. The Program invested $17, 000.00 dollars in new FLS training equipment with the purchase of three simulation trainers. The FLS training room is available to all residents during normal business hours and is able to accommodate up to three resident trainees practicing simultaneously. PGY 1 residents are provided with an introduction to FLS and FLS level 1 course training. PGY 2, and 3 residents receive FLS level 2 course training and as a PGY 3 the resident is given a pretest on their skills prior to their certification test for Fundamentals of Laparoscopic Training. Fundamentals of Endoscopic Training(FES) is provided to all residents. The program invested, along with two other departments, in purchasing an Endoscopic Simulator for resdients to complete the simulation portions of the FES curriculum. The FES curriculum is spread across the PGY 1, 2, 3, 4 years and as a PGY 4 the resident is given a pretest on their skills prior to their certification test for Fundamentals of Endoscopic Training. We also have a vascular anastomosis suture lab that was developed here at Brown / RIH. The PGY 2 residents are tested and assessed on this anastomosis model. All workshop and sessions are monitored and run by faculty members. Residents are tested and the metrics are generated and added to the residents’ milestones providing data regarding the residents’ technical performance and also the progression of an individual resident in technical skills. We also have a robotics curriclum designed to help residents understand the basic components of a robotic operating system, recognize patient saftey issues, and become comfortable with basic manipulation of robotic instruments. The curriclum is performed during the PGY 2 and 3 years. The resident will complete an Introduction to the Robot session with an educational represenative of Intuitive Surgical, complete modules on the simulator and perform 5 bedside assists with faculty. There is also an advanced training opportunity for those residents who anticipate performing robotic operations after residency.
Mock oral examinations are offered to the categorical PGY 3, 4, 5 level surgical residents through our participation in the New England Mock Oral Exchange Program. This process simulates the American Board of Surgery Oral Certifying Examination. In this program we send faculty members to various training programs as guest examiners and in return receive faculty guest examiners from other Mock Oral Exchange Programs. This factor of the examination - a resident being examined by an attending the resident has never worked with previously - is extremely valuable to provide appropriate levels of realism. Residents are scored in a pass fail grading system and are provided written feedback and suggestions for improvement on their performance. Metrics generated from this examination are added to the resident's milestones providing the data regarding the resident's level of clinical knowledge and decision making skills. The residents aggregated scores are also looked at to identify gaps in our surgery curriculum for the next year.
Self Directed Learning
Self directed learning plays a very important role in physician training. We believe that resident who apply themselves to self directed learning practices develop educational practices that prove invaluable throughout training as well as during their career as a physician. The Program fosters self directed learning elements into all assigned curriculum activities and provides multiple resources to allow motivated residents to engage themselves in educational activities. The amount of self directed learning engagement we expect from residents increases along with the PGY levels.
The PGY 1 intern creates a reading schedule for the year, prepares themselves for conferences and rotations by taking advantage of their SCORE membership reading journals and book chapters online, following modules on relevant topics, and taking practice quizzes.
The PGY 2 resident begins to develop their research skills, increase their understanding of health care systems and learn the practice of quality improvement in the development of their outcomes project. They prepare themselves for a more senior role by taking advantage of the assigned SCORE modules and their Discourse LLC membership, reviewing and making clinical decisions on patient care scenarios available in this online clinical management simulation program. They build upon their reading schedule developed as an intern.
The PGY 3 resident independently seeks out and works on additional clinical research opportunities above their assigned outcomes project. They utilize all resources available in SCORE to prepare for conferences and rotations. They continue to build their reading schedule and help provide leadership in the running of busy surgical services.
The PGY 4 resident takes advantage of the skills laboratory to practice their FLS skills independent of assigned practice sessions. They facilitate opportunities to meet with faculty identified as mentors to discuss patient care plans, disease processes, and operations. The PGY 4 also needs to prepare a history of surgery mini-grand rounds to understand the contributions of our surgical forbearers.
The PGY 5 resident organizes learning opportunities for their team and informal teaching sessions for junior residents. They utilize all resources available in SCORE to prepare for conferences and rotations as well as expanding their reading schedule to prepare for the ABS Qualifying Examination. Each PGY 5 resident is given an opportunity to lead in administrative roles such as Administrative Chief Resident, M&M Liaison, Clinic Chief, Senior Conference Liaison, and Medical Student Liaison. All administrative roles are facilitated and guided by faculty mentors.
In recognition for the need of both clinical and academic physicians in the current and future healthcare environments, the training program offers two tracks of surgical training to our categorical residents. Those residents who wish to purse an academic career may enter into two years of basic science research in one of several research opportunities available within the Department of Surgery. This opportunity occurs after completion of the residents PGY 2 year. Two to three residents per year pursue this track.
For those residents who do not elect a laboratory experience, the clinical track allows for completion of the categorical program in five years with the inclusion of a clinical outcomes research project. Starting in 2002 an outcomes research project became part of the surgical curriculum for the clinical track in general surgery. It is hoped that this project inspires a lifelong desire of our residents to assess their outcomes in a realistic manner and that this knowledge will make them better physicians. At the end of the internship year the resident selects a project they will pursue for two years and a faculty mentor with whom they will collaborate. During the first six months, residents are dedicated to identifying a faculty sponsor, writing a proposal and submitting it to the Institutional IRB. The following twelve months are dedicated to the evaluation of data. The final six months are focused on data analysis and preparation of a presentation to the faculty and fellow residents at a Surgical Grand Rounds at the end of their PGY 3 year. Throughout the resident's experience with an outcome project they meet multiple times with their faculty mentor for guidance and feedback on their research. All residents submit their outcome projects for presentation at national and regional conferences. Residents are required to attend and provide an update on their project at quarterly meetings with either Drs. Harrington or Miner and their fellow residents. This meeting is much like a bench research laboratory meeting, in that it allows for teaching and mentoring of research topics and allows residents to be peer reviewed of their ideas and formulate solutions to problems encountered. The schedules of outcome project meetings along with the meeting's objectives are set at the start of the academic year. Residents are evaluated midway through this process and a summative final evaluation of their project is completed following their Grand Rounds presentation of their project at the end of PGY 3 year.
PGY 4 general surgery residents are members of the Department of Surgery Quality Improvement Committee and participate in a quality improvement initiative during this year. The general surgery residents are asked evaluate a surgical data base and present their findings at a QI/M&M Conference Resident preparation for this presentation requires meetings with faculty mentors for guidance and feedback on their assessment of data and presentation of their findings. The Department of Surgery databases available for the 4th year resident to choose from include: NSQIP, UHC, STS, UNOS Trauma 1, BOLD (bariatric).
Surgical residents are encouraged to present their research at national, international and regional meetings. In the past academic year (7/2018-6/2019) 18 residents presented 27 presentations at regional and national meetings. Several peer reviewed articles were also co-authored by surgical residents during the past academic year.
Residents as Teachers and Leaders
Surgical residents begin to develop their teaching skills during the first year of their clinical training. The Training Program begins the formal teaching of resident teachers by first guiding them on how they present surgical topics in educational forums to their peers and faculty members. In Boot camp, residents are provided with several didactic sessions on developing teaching skills. Presentations by faculty include:
- Creating slides/handouts, making presentations interactive, being prepared for questions
- How to give and receive criticism, how to use both positive and negative feedback on your presentation to improve your teaching skills
- How to evaluate others
- Successful methods for self directed learning.
- Ethics of surgical education
- Leadership of groups and organizations
Beginning in the PGY 1 year and through the end of PGY 3 year, surgical residents are taught and gain experience on how to lead and teach within a formal Resident Teaching Conference. The surgical resident is assigned a surgical topic for presentation at Intern Resident Conference. The surgical resident is required to review the presentation with the assigned faculty proctor prior to presentation to students. Both the resident and the faculty proctor are present at the lecture. The role of the faculty proctor is to listen and evaluate the resident on their teaching skills, only interjecting if clarification of a point is necessary and not being adequately addressed by the resident presenter.
Senior residents are taught how to examine medical students during regular proctored oral exams given in the student surgical clerkship. Senior residents also gain hands on experience teaching junior residents and students through participating in skills workshops, as well as mentoring and advising students and junior residents on case presentations of patients or surgical topics. From these experiences, many residents have received kudos from graduating classes at the Alpert Medical School of Brown University.
The resident's clinical experience is complemented by a rigorous academic conference schedule. This schedule is designed to promote resident and faculty advancement in surgical knowledge and is also utilized to develop and hone resident presentation skills in a variety of settings. The interdisciplinary nature of several of the conferences enhances the educational experience and promotes an appreciation for various views and approaches to surgical problems and issues.
Tuesday mornings are designated as academic mornings. During this time residents have three hours of protected educational time and are excused from regular patient care activities. In addition to Grand Rounds, all residents are expected to attend their respective Intern Resident Conference/Boot Camp Series, or Senior Resident Patient Management/ Basic Science Conference.
Intern Resident Conference is specially designed to teach intern residents the essential principles and topics of surgery. Following the conclusion of Boot Camp, Junior Resident Conference sessions are proctored by the Intern Conference Director, Associate Program Director and/or an invited faculty preceptor. Throughout the year, each categorical intern will prepare his/her assigned topic utilizing a case presentation format teaching the major points of the area throughout the presentation. Additionally, each PGY 2 and 3 resident will prepare two assigned topics utilizing a case presentation format teaching the major points of the area throughout the presentation. Faculty will provide feedback in the form of a written evaluation and provide a critique of the residents teaching skills. Also, included are several attending lectures on essential topics of surgery. Residents will have access to all of the web-based educational resources available through SCORE.
Senior Resident/ Basic Science Patient Management Conference focus is to have an in depth literature based discussion of clinical cases to define appropriate clinical management algorithms and controversies. The assigned topics coincide with a basic science topic to provide a cohesive education experience and well rounded treatment of each area. This conference is overseen by the Program Director and Associate Program Director, and is also proctored by faculty members on a rotating basis. Residents are responsible to arrive prepared for this interactive conference. Residents utilize SCORE for review of the weekly topic. In addition to the residents reviewing the current treatment of surgical disease, the associated educational modules and quizzes in SCORE are expected to be completed prior to the Senior Resident Conference.
Quality Improvement/Morbidity & Mortality Conference are a department wide, site specific mandatory conference held weekly at Rhode Island Hospital, The Miriam Hospital and the VA Medical Center. Residents, students and faculty located at each respective site participate in their site's Quality Improvement Conference. The primary purpose of these forums is to provide quality assurance and peer review. Management complication and outcome improvement are the main emphasis. Discussion is literature based with references provided for each presented case. Presenting residents are expected to create a PowerPoint presentation and are evaluated on the quality of their presentation, understanding of the issues and on the manner of presentation by the Program Director, or Associate Program Director at RIH, the site directors at TMH and the VAMC.
Divisional Service Conferences are held weekly. Residents and students rotating on the service and faculty members of the Division Service participate in these conferences. Rhode Island Hospital holds eight Divisional Conferences each week, The Miriam Hospital and the VAMC each hold one Divisional Conference each week. All Division Service Conferences are directed and proctored by the Division Director, and or designated faculty member. All aspects of patient disease, including pathophysiology, surgical technique and patient management are addressed and discussed.
The Division of Trauma conference is a weekly conference encompassing the disciplines of Neurosurgery, Orthopaedic Surgery, Urology and Critical Care. The chief resident on the trauma service is responsible for preparation of cases in coordination with the specialty chief resident. Trauma faculty mentors provide guidance and feedback to residents on their presentations. This conference is an interactive format where attending staff review trauma management with all attendees. On the last Monday of the month this conference serves as a Quality Improvement/Mortality and Morbidity Conference for the Division of Trauma.
Surgery/ Trauma/ Medicine ICU Combined Conference is a joint conference held weekly. This conference serves as a forum for case presentations of critical care patients and issues. The medical and surgical critical care attendings facilitate discussion amongst the residents regarding intensive care concerns. Residents from the medical, surgical and trauma intensive care services compare and contrast management plans for critically ill patients.
Trauma and Emergency Medicine Combined Conference is a monthly joint conference with the Trauma Service and Emergency Medicine Department attendings and residents. This conference is an opportunity for both services to explore the management of trauma patients on their arrival to the Emergency Department. Initial assessment, patient management and communication skills are explored and expanded upon during this conference. Additionally, in-depth review of the evaluation and management of individual trauma patients that have undergone a quality assurance review occurs.
Trauma Morning Report is a daily conference for residents, students rotating on service, the on-call and post-call trauma attending, and Trauma Division attendings. This conference is multifunctional and serves as an educational conference and as a morning sign out. All patients are presented comprehensively by the admitting trauma resident, along with live review of radiologic studies on the PAC system. The History and Physical is updated, completed and signed by the admitting attending following presentation. Additionally, the service listing of patients is reviewed and the status and care plans are communicated.
Surgical Grand Rounds and special lectureships feature both local, nationally and internationally recognized faculty. All major areas of surgery are addressed as well as medico-legal and ethical issues. The surgical Grand Rounds audience is comprised of surgical faculty, invited guests, residents and medical students.
The Department of Surgery hosts five special lectureships within the surgical Grand Rounds series. Each lectureship focuses on a specific area of general surgery. An internationally renowned surgeon is invited and spends two days with our residents and faculty as a Visiting Professor in the Department of Surgery. During this time, the Visiting Professor will address the Department on his/her clinical and research interests, as well as attend a resident round table discussion. Faculty members and research residents present their research and clinical residents present interesting cases to the Visiting Professor. Some lectureships are given annually and some are semi-annual. (Addendum #1)
Our program utilizes general surgery milestones to determine resident performance within the six ACGME Core Competencies. General surgery has sixteen milestones which are competency based developmental outcomes that can be demonstrated progressively by residents. Collection of milestone data comes from multiple evaluations and sources. All information is entered into our milestone data base producing a sixteen point radar plot report on each resident's progress within the six ACGME core competencies. As we are an ACGME accredited training program we are required to appoint a Clinical Competency Committee to review all resident performance data and report their recommendations to the Program Director. The Program has developed a nationally recognized "Radar Plot" organized to summarize the multiple evaluation forms for each resident. Utilization of a radar plot to review the milestone data during the Clinical Competency Committee meetings helps to direct the discussion of each resident's growth. Areas of concern are quickly identified and Committee members can easily target problem areas to address in their recommendations to program leadership. With the recommendations from the Clinical Competency Committee, the Program Director can then assess the needs of resident learners, implement support, guidance and mentorship where needed and as appropriate for individual residents.
Special Features of our Training Program
There are many excellent attributes of the Alpert Medical School, Brown University, General Surgery Training Program. A few curriculum elements stand out as unique among our peer training programs.
We are fortunate to have an ACGME and ABS approved international four week rotation. With our longstanding relationship with Tenwek Hospital, dedicated funding to support resident travel to Tenwek, and commitment of dedicated teaching faculty, we are able to provide a unique, well structured international elective rotation. Russell E. White, MD is the Tenwek Medical Mission Hospital's Medical Superintendent. Dr. White graduated from the Brown University General Surgery Training program in 1995, and holds an Academic appointment as an Associate Clinical Professor of Surgery at Alpert Medical School, Brown University. Board Certified in General Surgery by the American Board of Medical Specialties since 1996, Dr. White is also the current Program Director for the Tenwek Hospital General Surgical Residency Program affiliated with the College of Surgeons of East, Central, and Southern Africa/Pan-African Academy of Christian Surgeons. Dr. White is also accompanied by two Brown graduates who took faculty positions at Tenwek Hospital, Dr. Andrea Parker and Dr. Robert Parker. This experience is held in Bomet, Kenya at the Tenwek Medical Mission Hospital, and provides trainees with an opportunity to participate in an educational experience that exposes the resident to care for patients with diseases they would rarely see in the United States. Since the Surgery Department at Tenwek is responsible for all subspecialty surgery, the resident obtains operative experience within subspecialty areas of urology, obstetrics, gynecology, plastic surgery, otolaryngology, orthopaedic, neurosurgical, thoracic, trauma, and pediatric surgery. The other unique educational characteristic of this elective is the opportunity for resident growth of awareness to the profound societal responsibilities that come with surgical training.
We offer our categorical trainees selective rotations during their PGY 2 and 3 year. The PGY 2 Selective is designed to allow the resident to participate in a self-selected rotation where they can explore an area of academic interest and broaden their surgical horizon. The PGY 3 Selective is designed to allow the resident to explore a subspecialty in order to gain a better understanding of areas of potential fellowship training they may be considering. Each of these rotation experiences provides the residents with opportunities to identify faculty mentors associated with the resident’s area of interest as well as a dedicated time for self-reflection on their training experience to date and set goals for future training.