Clinic

In clinic, residents are encouraged to review the medical chart of the upcoming patient and any pertinent imaging. Discuss with your attendings how he/she prefers to organize the day. Some will encourage you to go in and see the patient before them and gather the medical history and formulate an idea of what you think is going on; others may prefer that you see the patient simultaneously with them, as several have long-term patients that they know very well.

Inpatient Rounds

The surgical oncology service is typically composed of interns, junior/senior residents, a surgical fellow, and attendings. Try to be an integral part of the team. Select a couple new patients or continue to follow the patients that you have observed in the clinic or operating room. You can certainly ask the upper level resident or fellow for guidance on this. Learn to manage their primary and secondary conditions while they are in the hospital, with an emphasis on peri-procedural management. Many patients have post-operative complications or are admitted for diagnoses that require the services of interventional radiology (see below).

Operating Room

You are encouraged to scrub into as many cases as possible, ideally covering a wide range of surgical techniques and pathology. Nonetheless, a couple of these are extremely helpful in developing relevant clinical knowledge for the future interventional radiologist. Be sure to ask the attending before the case begins if this will be a good case for you to scrub. You are expected to have a basic understanding about the patient, operation, and anatomy and learn from various organ transplantation procedures, particularly the liver and kidney.

Diagnostic Imaging

The resident’s core diagnostic radiology skills will be very useful and may frequently be called upon throughout the rotation. Although surgeons also review the imaging, you will be considered the expert radiologist. In the clinic setting, many times the patient will be seeing the surgeon for the first time and only have imaging from an outside hospital without a report. In this case, you are often called upon to scan through the images and give your opinion. During inpatient rounds, you may be the first to review the images on your patients from the list before any attending has a chance to. This is a great time to learn and build upon your CT and MRI abdominal imaging knowledge, as these patients often have complicated medical conditions that require advanced imaging. This encourages you to think on your feet and formulate an opinion on the spot, which is a great skill to develop. Furthermore, this experience will improve your clinical judgement as you observe how surgical clinicians decide when an imaging study is indicated or needed, how they respond to radiologists interpretations and dictation styles, and how our reports affect patient management and their course in the hospital.

Relevance to Interventional Radiology

Numerous interventional procedures aid in the care and management of transplant patients. You may be called upon to perform or expound upon these procedures and having a basic understanding of their indications/contraindications and having the basic skills to perform these tasks is crucial. Become familiar with the following common interventional procedures that you may encounter:

  • Biliary drain placement
  • Drain placement for surgical abscess formation
  • Nephrostomy tube placement
  • Biliary stent placement
  • Renal artery stent placement
  • Ureteral stent placement
  • IVC filter placement

Specific Rotation Goals and Objectives

  • History taking and physical examination
    • Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
  • Clinical Knowledge
    • Become familiar with the anatomy and vascular supply of commonly transplanted organs
      • Liver
      • Kidney
      • Lung
      • Other Common Donor Organ Procurements (i.e. heart)
    • Know the indications and contraindications for organ transplant in regards to the above mentioned organs
    • Become familiar with the alternatives to transplant and the therapeutic options that may still exist for the patient
    • Learn the principals of pre and postoperative management
    • Develop a cost-effective and rationale preoperative workup including consults, laboratory testing, radiology studies and pre-procedural risk stratification
    • Fluid and electrolyte management/replacement
    • Basic pharmacological management
      • This includes sedation, pain, and antibiotics
    • Recognize and evaluate a critically ill or unstable patient or a patient who is developing new complications
      • With the goal of developing a working diagnosis and treatment plan
    • Become familiar with the different types of shock and how each are recognized, stabilized and treated
      • Neurogenic
      • Cardiac
      • Hypovolemic
      • Septic
    • Wound Care
    • Follow-up and outpatient management
      • This includes referrals for resources, social work, rehab and PM&R
  • Procedural Goals
    • Demonstrate skill in basic surgical techniques, including:
      • Suturing and knot tying
      • Exposure and retraction
      • Knowledge of instrumentation
      • Incisions
      • Closure of incisions
    • Develop a basic understanding of the common organ transplantation procedures, particularly the liver and kidney.

Systems Based Practice

  • Take on new patients and consultations with the goal of assigning team resources to address them in an appropriate and timely manner
  • Be able to coordinate care within the team over multiple patients and multiple problems of varying urgency (i.e. be able to triage effectively)
  • Coordinate hospital and physician resources in regards to transferring patients who are critically ill from other institutions
  • Complete full consult notes and progress notes every day on the patients that you are covering in a detailed and accurate format that is easily translatable to other services
  • Be an active, effective and efficient team member by effectively transferring care between duty hours completely and responsibly

Practice-Based Learning and Improvement

  • Shows appropriate use of consultation with medical and non-medical services, including special diagnostic studies
  • Uses evidence from the medical literature to answer clinical questions
  • Identifies areas for potential improvement in personal delivery of care
  • Maintains a positive attitude towards learning, including attendance and participation on patient rounds and conferences, and evidence of reading or other methods of gaining knowledge
  • Participates actively in teaching others, including students, residents, and faculty
  • Serve as a radiology advisor/liaison to the team when called upon
  • Educate the team regarding imaging utilization, radiation concerns and
  • Develop the clinical skills necessary to successfully manage a patient throughout the peri-procedural course, to help facilitate improved non-procedural interventional radiology patient care during your career.

Patient Care

  • Review past and current imaging on all patients you are involved with.
  • Perform procedures within the level of your knowledge under supervision.
  • Assist in the admission and discharge of patients when appropriate.
  • Assist in consults when appropriate.

Interpersonal and Communications Skills

  • Presents a patient effectively and efficiently
  • Communicates with patients and concerned others effectively
  • Writes accurate and complete entries in the medical record
  • Works constructively as part of a team
  • Exchanges information effectively and efficiently during rounds that reflects pertinent issues and problems, current therapeutic plans, and expected complications and issues
  • Establish therapeutic and empathetic relationships with patients and their families

Professionalism

  • Remember you are a guest in another specialties’ practice. Be prompt, present,
  • Take on progressive amounts of responsibilities during your rotation and live up
  • Dress code: White coat and business casual attire is expected in the outpatient clinic. Scrubs under white coat may be acceptable on the floor depending on your attending. Scrubs alone are acceptable during procedures.

Additional Resources

  • Surgery Books available on ClinicalKey (Title – Author)
    • Hepatobiliary and Pancreatic Surgery – Garden
    • Atlas of General Surgical Techniques – Townsend
    • Essentials of Surgical Oncology – Sabel