AAFP Core Educational Guidelines

Care of the Surgical Patient: Recommended Core Educational Guidelines for Family Practice Residents



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Am Fam Physician. 1999 Sep 1;60(3):1030-1036.

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

Surgical care may be defined as the body of knowledge, skills and attitudes necessary to evaluate and manage conditions and disorders requiring operative intervention.

Attitudes

The resident should develop attitudes that encompass the following:

  1. Recognition of the importance of family physician and surgeon collaborating as partners in the evaluation of and decision making for the care of surgical patients.

  2. Awareness of the principles involved in differentiating the causative origin of clinical symptoms resulting in the need for medical versus surgical intervention.

  3. Sensitivity to the patient's and family's concerns and anxieties regarding the potential need for surgical intervention.

Knowledge

  1. Basic principles of surgical diagnosis

    1. Basic surgical anatomy

    2. Wound physiology, care and healing processes

    3. Clinical assessment, including history, physical examination, laboratory evaluation and differential diagnosis of key signs and symptoms of surgical conditions

    4. Invasive versus noninvasive diagnostic tests

    5. Anesthesia

      1. Premedication

      2. Agents

      3. Routes of administration

      4. Toxicity

      5. Resucitation mentods

    6. Recognition of surgical emergencies

    7. Ethical and legal considerations

      1. Informed consent

      2. Quality of life

      3. End-of-life issues

  2. Preoperative assessment

    1. Surgical risk assessment

    2. Comorbid diseases

    3. Antibiotic prophylaxis

    4. Patient preparation (bowel, etc.)

  3. Intraoperative care

    1. Basic principles of asepsis and sterile technique

    2. Patient monitoring

    3. Fluid management

    4. Blood requirements

    5. Temperature control

    6. Use of basic surgical instruments

  4. Postoperative care

    1. Routine

      1. Wound care

      2. Patient mobilization

      3. Nutritional management

      4. Pain management

      5. Suctions and drains

    2. Common complications

      1. Fever work-up and management

      2. Wound dehiscence

      3. Urinary retention

      4. Hemorrhage

      5. Pneumonia

      6. Atelectasis

      7. Fluid overload

      8. Transfusion reaction

      9. Thrombophlebitis

      10. Pulmonary embolism

      11. Oliguria

      12. Respiratory insufficiency

      13. Ileus

      14. Infection

      15. Shock

    3. Long-term follow-up

  5. Outpatient surgery

    1. Patient selection

    2. Conscious sedation

    3. Postoperative observation principles

    4. Follow-up

  6. Office care of common conditions

    1. Lumps and bumps

    2. Simple lacerations

    3. Superficial burns

  7. Approach to the care of common surgical conditions

    1. Abscesses

    2. Aortic aneurysm

    3. Appendicitis

    4. Arterial insufficiency

    5. Benign neoplasia

    6. Bowel obstruction

    7. Breast masses

    8. Carpal tunnel syndrome

    9. Colon cancer

    10. Coronary artery disease (obstruction)

    11. Cysts and hematomas

    12. Diverticuli

    13. Gallbladder disease

    14. Ganglia

    15. Gastrointestinal hemorrhage

    16. Hemorrhoids

    17. Hernias

    18. Intervertebral disk herniation

    19. Lung cancer

  8. Shared management of common general surgical conditions

    1. Anal fistula, fissure or perianal abscess

    2. Carcinoma

    3. Esophageal varices

    4. Fasciitis

    5. Incarcerated hernia

    6. Intussusception

    7. Malabsorption

    8. Obstruction

    9. Pancreatic disease

    10. Polyposis

    11. Regional enteritis

    12. Ruptured viscus

    13. Ulcerative colitis

  9. Organ donation and transplantation

Skills

  1. Preoperative assessment

    1. Surgical risk evaluation

    2. Physical assessment

    3. Radiographic assessment

    4. Noninvasive diagnostic procedures

    5. Invasive diagnostic procedures

      1. Paracentesis

      2. Nasogastric lavage

      3. Peritoneal lavage

      4. Thoracentesis

      5. Tube thoracostomy

      6. Bladder aspiration

      7. Central venous access (central venous pressure, Swan-Ganz catheter)

      8. Venous cutdown

      9. Arterial puncture/catheterization

      10. Needle aspiration/biopsy technique

  2. Emergent surgical techniques

    1. Cricothyroidotomy

    2. Needle thoracostomy

    3. Pericardiocentesis

  3. Intraoperative skills

    1. Preparation and draping of operative field

    2. First assist at major surgery

    3. Basic use of surgical instruments

    4. Incision and dissection

    5. Exposure/retraction

    6. Hemostasis

    7. Estimation of blood loss

    8. Fluid replacement

    9. Wound closure

      1. Technique selection (ligature, staples, adhesives)

      2. Suture selection

      3. Drains

      4. Dressings

  4. Postoperative care

    1. Suture removal

    2. Dressing changes

    3. Drain removal

  5. Minor surgical techniques

    1. Local anesthesia

    2. Simple excision

    3. Incision and drainage of cysts and abscesses

    4. Aspiration

    5. Ear piercing

    6. Foreign body removal

    7. Minor burns

    8. Vasectomy

    9. Cauterization/electrodesiccation

    10. Punch biopsy

    11. Wound debridement

    12. Enucleation/excision of external thrombotic hemorrhoid

    13. Rectal polyp removal

    14. Nail surgery

Implementation

The implementation of this curriculum segment should combine a minimum of two months of block rotations and longitudinal learning experiences throughout the 36 months of training. The curricular content should be required and integrated into the conference schedule and into teaching activities in the family practice center. Relevant materials should be prominent in the residency library.

Resources

Wolcott MW, ed. Ferguson's Surgery of the ambulatory patient. 5th ed. Philadelphia: Lippincott, 1974.

Wolcott MW, ed. Ferguson's Surgery of the ambulatory patient. 5th ed. Philadelphia: Lippincott, 1974.

Way LW, ed. Current surgical diagnosis and treatment. 10th ed. Norwalk, Conn.: Appleton & Lange, 1994.Condon RE, Nyhus LM. Manual of surgical therapeutics. 9th ed. Boston: Little, Brown, 1996.

Sabiston DC Jr, Lyerly HK. Textbook of surgery: the biological basis of surgical practice. 15th ed. Philadelphia: Saunders, 1997.

Pfenninger JL, Fowler GC. Procedures for primary care physicians. St. Louis, Mo.: Mosby, 1994.


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