AAFP Core Educational Guidelines

Care of the Surgical Patient
RECOMMENDED CORE EDUCATIONAL GUIDELINES FOR FAMILY PRACTICE RESIDENTS

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the American College of Medical Genetics, the Association of Professors of Human and Medical Genetics, 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. Resuscitation methods
   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.

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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