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. Consider the common cancers and metastatic disease to be encountered: neuroendocrine, pancreatic adenocarcinoma, colon cancer, hepatocellular carcinoma.

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.

Recommended procedures:

  • Hepatectomy
  • Hepatic artery infusion pump insertion
  • Pancreaticoduodenectomy (Whipple Procedure)
  • Intraoperative radiofrequency/microwave ablation of liver metastases
  • Distal pancreatectomy and splenectomy

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

The objective of the IR resident is to further develop their clinical acumen and judgment, ultimately assisting in their progression towards becoming a more clinically competent practicing interventionist. Oncologic patients with advanced disease and those in the immediate postoperative state will often require the services of interventional radiology. As part of the referring team, the IR resident has the unique opportunity to learn how to successfully manage a patient throughout the peri-operative period. This rotation is also an excellent opportunity to enhance your knowledge of the indications and limitations of the common interventional radiology procedures this patient population typically requires. Furthermore, you will observe how surgical oncologists interact with other services, including interventional radiologists and medical oncologists.

  • Frequently requested interventional radiology procedures:
  • TACE and Y-90 radioembolization
  • RF and microwave ablation
  • Percutaneous transhepatic cholangiogram and biliary catheter placement
  • Postoperative abscess drain
  • Mediport and CVC placement
  • IVC filter placement and retrieval
  • G/J-tube exchange
  • Percutaneous nephrostomy tube placement
  • Visceral angiography and embolization for post-op hemorrhage

Specific Rotation Goals and Objectives

  • Clinical Knowledge
    • Practice and refine the physical exam and medical history skills learned during internship year (PGY-1)
    • Gastrointestinal tract anatomy
    • Know anatomic location and relations of the esophagus and stomach, liver and biliary tree, pancreas, small and colonic bowel
    • Know the physiology of the liver and biliary tree, and pathophysiology of bile production and formation of biliary lithiasis
    • Know the principles of cancer genetics and carcinogenesis. and the common familial cancer syndromes, ascertain the risk for developing cancer, and provide counseling to patient and family members
    • Recognize pancreatic cancer biology, staging, and results of various therapies
    • Determine the presence of metastasis and extent of disease by the judicious use of diagnostic tests (CT, ERCP, EUS), propose a treatment plan based on extent of disease and the patient’s symptoms, determine the need of palliative care (i.e. biliary stenting, nutritional support), perform pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy
    • Recognize liver cancer biology, staging, and results of various therapies
    • Determine a patient’s operability based on the physiologic status and reserve, propose a treatment plan based on the extent of disease and the patient’s symptoms, and perform liver resection
    • Successfully manage and medically optimize patients for their planned procedure/surgery
    • Prepare for and clinically manage common post-operative/procedural complications
    • Understand and be responsible for the management of
      • Intra-abdominal and intra-pelvic drains
      • Abdominal incisions
      • Enteric tubes
    • Formulate treatment and appropriate follow-up plans for the patients you encounter
    • Understand the various tumor staging systems and utilize these systems in the management of patients
    • Become competent in the appropriate usage of tumor markers (i.e. CEA, CA-125, CA 19-9, AFP, PSA, HCG), tumor excretory metabolites, and diagnostic cytohistologic techniques in the screening and monitoring of disease recurrence/progression.
    • Understand the indications for curative versus palliative treatment and be able to formulate treatment plans for both.
    • Become familiar with currently used chemotherapy, radiotherapy, and immunotherapy protocols for common cancers.
    • Become comfortable with the management and treatment of oncologic pain, including proper dispensing of narcotics. Become familiar with formulations, dosages, potency, and side-effects (NSAIDs, opiates, etc.)
    • Know how to manage electrolyte abnormalities (K, Ca, Mg, Na, Phosphate)
    • Know how to assess and managing patient’s fluid status using renal function/creatinine, urine output, vitals, physical exam findings, CVP, and ultrasound
    • Know how to manage a febrile patient by determining source of infection and selecting appropriate antibiotics (broad coverage and bacteria-specific)
    • Know the etiologies of and management of shock (cardiogenic, septic, hypovolemic, traumatic, neurogenic)
  • 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 these procedures:
      • Hepatectomy
      • Hepatic artery infusion pump insertion
      • Pancreaticoduodenectomy (Whipple Procedure)
      • Intraoperative radiofrequency/microwave ablation of liver metastases
      • Distal pancreatectomy and splenectomy

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