General Surgery Residency Program

Our Philosophy

The William Beaumont Army Medical Center General Surgery Residency Program is a well rounded community based program that emphasizes the need for the military general surgeon to be capable in all areas of surgery. This philosophy is based on the likely deployment of graduates and faculty to remote locations in austere conditions. Lack of surgical specialists in these locations requires the general surgeon to have a broad experience during training that will insure preservation of the fighting strength of the United States military as well as providing surgical care as required to the local population.

Organizational Structure

The WBAMC General Surgery Residency Program is administratively controlled by the General Surgery Service. WBAMC is a joint residency program with Chandler Regional Medical Center in Chandler, AZ. WBAMC is the parent institution, providing 47 of the 60 months of training, while Chandler Regional Medical Center provides a total of 10 months of training. The General Surgery Service also administratively controls the General Surgery Outpatient Clinic, the General Surgery Inpatient Service, the Thoracic Surgery Service, the Colorectal Surgery Service, the Trauma Service, the Surgical Endoscopy Service, and Surgical Critical Care in the Surgical Intensive Care Unit. The Vascular Surgery Service, under the Department of Surgery, plays an intrinsic role in the education of the surgery residents.

The General Surgery Service is supported and controlled by the Department of Surgery along with eight other services, which include:

• Anesthesiology
• Cardiothoracic Surgery
• Neurosurgery
• Ophthalmology
• Otolaryngology
• Plastic Surgery
• Urology

Clinical Care is delivered by three separate ward teams: General Surgery East, General Surgery West, and Vascular Surgery. In addition, an ICU team exists to facilitate care of the critically ill surgical patients.

The ward team structure provides quality patient care in a supervised environment which stimulates the development of clinical knowledge, maturity, surgical judgment, technical skills and problem solving by residents at each level. The ward team operation is intended to expose the residents to the full scope of patient care which begins with the initial consultation, extends through the diagnostic work-up and preop preparation, peaks in the operative and postop management and is finally complete when the patient has fully recovered.

The General Surgery ward teams consist of a Chief Resident (PGY 4 or 5), a Junior Resident (PGY 2 or 3), 1 or 2 Interns (PGY 1), and 1 or 2 Medical Students. Each team is assigned attending staff surgeons who provide supervision and guidance in the full spectrum of General Surgery. Both General Surgery ward teams perform alimentary tract surgery, gastrointestinal endoscopy, colorectal surgery, oncology surgery, endocrine surgery, general thoracic surgery, general pediatric surgery, general head and neck surgery, diagnostic and therapeutic laparoscopy, outpatient minor surgery, surgical critical care, trauma care and surgical research.

The Vascular team consists of a Chief Resident (PGY 4 or 5), a Junior Resident (PGY 2 or 3), an Intern (PGY 1) and one or two Medical Students. The Vascular team is assigned one Vascular staff attending who supervises the residents in the full range of vascular surgery. This covers diagnostic procedures including ultrasonography, duplex scanning, and arteriography. Also, therapeutic procedures including placement of intra-arterial stents, angioplasty, catheter directed thrombolytic therapy, and open venous and arterial repair are performed routinely by the Vascular Service.

Rotations at Affiliated Institutions

WBAMC augments resident training in surgical care of high volume penetrating trauma, burn surgery, transplant surgery and community surgery with rotations at affiliated hospitals.

Residents rotate at Chandler Regional Medical Center in Chandler, Arizona (a suburb of Phoenix) for a total of ten months during their PGY 2-5 years. Chandler Regional Medical Center is a Level I trauma center which also has an acute care surgical service. The number of months spent at Chandler each year are as follows:

• PGY2 — 1 month
• PGY3 — 2-4 months
• PGY4 — 2-3 months
• PGY5 — 2-3 months

Burn care is taught by the Arizona Burn Center (ABC), which is part of Maricopa Integrated Health in Phoenix, Arizona

Pediatric surgery is learned during a community rotation at El Paso Children's Hospital in El Paso, Texas during the PGY4 year.

Transplant surgery, to include patient selection, organ harvest, preoperative patient preparation, management of immune suppression, technical aspects of transplant surgery and post-operative transplant patient care, are learned on the transplant service at Chandler Regional Medical Center. Residents also learn how to manage immune suppression and its complications and to identify and treat graft rejection. This transplant rotation is combined with the cardiothoracic service which gives the resident unique exposure to required training in cardiothoracic surgery.

Surgical Caseload

The WBAMC General Surgery Residency Program focuses the responsibility for all aspects of a patient's care on the resident surgeon and his ward team. The ward team system allows the residents to manage a patient, with a single attending, from initial consultation to post intervention convalescence. This management includes the planning and execution of the work-up, preoperative preparation, proposed surgery, postoperative care and the management of any complications.

Breast

Both General Surgery Ward teams perform breast cancer screening, breast cancer follow-up, breast biopsies and definitive breast surgery for malignant disease, which includes immediate reconstruction in conjunction with the Plastic Surgery Service. Malignant pathology, adjuvant therapy, and multi-modality treatment are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Skin and Soft Tissue

Both General Surgery ward teams perform surgery on skin and soft tissue lesions. Surgery for melanomas, basal cell carcinomas, sarcomas, nerve and muscle disorders, and lymphadenopathy are performed in close association with the Dermatology, Plastic Surgery, Orthopedic Surgery and Medicine services. Malignant pathology, prognosis and multi-modality treatment are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Alimentary Tract

Both General Surgery ward teams perform general alimentary tract surgery. The number of referrals for laparoscopic anti-reflux procedures and specialized colorectal surgery are increasing in response to the addition of surgeons with special expertise in these areas. The increased volume of endoscopy performed by the General Surgery Service has also recouped patients requiring alimentary tract surgery who were formerly being disengaged from care and referred to civilian facilities for their endoscopic work-up and definitive surgical treatment.

Abdomen

Both General Surgery ward teams perform the full range of abdominal surgery utilizing both open and laparoscopic techniques. There is a high volume of biliary tract disease in the local patient population and a moderate amount of surgical ulcer disease in the Veterans Affairs population, which provides our residents a sound experience in these areas.

Vascular

On the Vascular ward team, residents learn assessment of the vascular patient. They are exposed to non-operative care, patient selection for surgical intervention, appropriate patient work up, vascular surgery techniques, postoperative critical care, and ongoing post-surgical follow-up for these complex patients. Junior Residents gain technical experience creating dialysis A-V shunts, on venous operations and by participating on the major cases performed by PGY 5 residents. The absence of a Vascular Surgery Fellowship reserves all major vascular cases for the General Surgery residents, which results in an extensive experience. The presence of a Vascular attending has also broadened the scope of resident training in the diagnostic and therapeutic modalities of duplex scanning, angioplasty, intra-arterial stenting, catheter directed thrombolytic therapy, and angiography. Residents' experience on the Vascular Service also includes work with an interventional radiologist.

Head and Neck

Both General Surgery ward teams perform general head and neck surgery to include surgery of the thyroid, parathyroid, parotid, head and neck malignancies, neck dissections, penetrating trauma, and congenital cysts. In addition, close ties with the Dermatology, ENT, and Plastic Surgery services, permits the residents to participate in the work-up, surgery and management of patients with head and neck malignancies that present to these services. Malignant pathology, prognosis and multi-modality treatment are reviewed at the weekly Multi-disciplinary Tumor Board Conference. There are no ENT Residents at WBAMC, so our residents do H&N and Endocrine cases.

Endocrine

Both General Surgery ward teams perform endocrine surgery. The majority of patients are referred to General Surgery by the Endocrinology Service. A resident and attending review the case, arrange any additional studies for patient preparation, and then present the case at the weekly preoperative teaching conference for discussion and for the training benefit of all the residents. All thyroid and parathyroid cases generated by the ENT Service and all adrenal cases generated by the Urology Service involve the General Surgery residents in the preoperative planning, the surgery and the postoperative management. Malignant pathology, adjuvant therapy, multi-modality treatment and follow- up are discussed and reviewed at the weekly Multi-disciplinary Tumor Board Conference.

Trauma

Trauma management at WBAMC is a continuous part of the daily elective and emergent routines of all three Ward Teams. WBAMC manages approximately one third (1/3) of all the major civilian trauma in El Paso County and is a Level III Trauma Center. All major trauma cases requiring multi-disciplinary care and ICU management are managed by the General Surgery residents and their staff. The resident trauma experience is further augmented by rotating for several months at Chandler Regional Medical Center in Chandler, Arizona, which is a Level I Trauma Center.

Critical Care

Surgical Critical Care is integrated as a continuous part of the daily elective and emergent routines of all three ward teams. As a result, residents become very confident and capable of managing ICU patients along with their other duties. General Surgery residents will be consulted to oversee and assist in the critical care management of all patients admitted to the Surgical ICU from the other surgical services. A Board Certified Surgical Intensivist on the faculty supervises the overall care in the ICU and assists with complex cases. Formal ICU rounds are conducted with the residents and staff to monitor the progress, problems, and treatment plans for each patient. This provides the opportunity for residents to learn from every ICU patient and to have the broadest possible critical care experience over their five years of training.

The Intermediate Resident or Junior Resident is responsible to place a daily comprehensive note on each general surgery ICU patient. In addition, any significant procedures, clinical changes, and study results will be documented on the clinical record as needed. The SICU team resident is responsible for all chart documentation on off-service patients in the SICU. The Chief Residents must forecast SICU bed requirements for postoperative patients, track the bed census of the ICU's and cooperate in managing ICU beds to permit the ER to remain open for civilian trauma and the surgical services to perform elective surgery. Questions concerning bed management, the ER status of Trauma, and ICU requirements for elective surgery should be referred to the medical director of the SICU.

In addition to daily exposure to the ICU, Junior Residents and Interns rotate on the SICU Service. In addition to their duties as ICU resident, the Junior Resident also acts as the SOD (Surgeon on Duty) during the day. This allows residents on the other teams to concentrate either on the clinic duty or the operating room.

Sub-Specialty Rotations

The absence of surgical subspecialty fellowships permits General Surgery residents to be involved with all major Thoracic, Plastic, Otolaryngology, Urology, Neurosurgery, and Pediatric surgery cases. The subspecialty exposure is orchestrated to maximize resident involvement in patient care from initial consultation to postoperative management in each of the respective disciplines.

Thoracic Surgery

The Thoracic Surgery training goals are to familiarize residents with surgical pulmonary disease, to teach them thoracic anatomy and to provide them an operative experience, to include open thoracotomy. Both General Surgery ward teams perform non-cardiac thoracic surgery. Residents achieve the training goals by managing thoracic surgery patients and by performing progressively more complex procedures throughout the residency. Junior Residents begin with the placement and management of tube thoracostomies. Intermediate Residents perform thoracoscopic procedures and limited thoracotomies. Chief Residents progress to open thoracotomies with major pulmonary resections.

Pediatric Surgery

Residents rotate with a busy pediatric surgeon at a local hospital and do more than 50 cases per month. This occurs during the PGY 4 year with Pediatric Surgical Associates of El Paso. Residents gain experience by performing elective and emergency surgery on children to include herniorrhaphy, pyloromyotomy, vascular access, exploratory laparotomy, appendectomy, and selected congenital diseases, under the supervision of the pediatric surgeons.

Neurosurgery

The training goal of this rotation is to teach residents the assessment of the neurologic patient, the operative and non-operative management of head and spine trauma, the criteria for operative intervention, and techniques of invasive intracranial monitoring. Residents learn how to drill burr holes, turn a flap, perform a craniotomy and repair the dura. Finally, they gain experience in the critical care management of elective and emergent neurosurgery patients.

Orthopedics

The goals of this rotation are to provide residents experience in the assessment of acute orthopedic trauma, the assessment of hand injuries, the operative and non-operative management of orthopedic injuries, the criteria for operative intervention, and the use of splints, casts, and traction techniques to stabilize injuries. Residents at the PGY 1 level rotate for one (1) month on the Orthopedic Surgery Service to master these skills.

Transplant

The goals of this rotation is to familiarize the residents with the essentials of transplant surgery to include patient selection, organ harvest, preoperative patient preparation, management of immune suppression, technical aspects of transplant surgery and postoperative care. The residents also learn to identify and manage the complications of immune suppression and graft rejection. Residents at the PGY 4 level perform a one (1) month rotation on the Transplant Service.

Basic and Clinical Science Curriculum

Residents are assigned readings each week from a basic science text and a clinical surgery text in preparation for a faculty lecture, which will unify and highlight the clinically relevant points of the topic covered. The interns will have an intern-specific curriculum and small group sessions once per week.

Program Director's Intent for the
Basic Science and Clinical Science Curriculum

Cover the broad issues in General Surgery and familiarize residents with the basics of:

• Surgical Vocabulary and Terminology
• Surgical Anatomy
• Surgical Physiology
• The Inter-Relationship of Body Systems

Provide the staff with an objective measure of resident knowledge based on:

• Established, Uniform Core Curriculum
• Resident Scores on Periodic Curriculum Testing

Provide basis for further resident in-depth reading and study:

• Required to manage the care of patients during the:
  • Current Year
  • Remainder of the Residency
  • One's Future Career as a Surgeon
• Mandatory to score respectably on:
  • In-Service Examinations
  • Written Board Certification Examinations
  • Oral Board Certification Examinations

Attendance at lectures is mandatory for all surgical residents and interns, PGY 1-5, on rotations at WBAMC regardless of the rotation service or subspecialty.

• Absenteeism and tardiness are strongly discouraged
• Lectures begin promptly at 7:00 AM in the Surgical Conference Room

A weekly reading assignment will be given.

• A quiz over the reading material may be given and recorded to monitor resident performance.
• Residents will present topics on surgical care as assigned.

Performance on the American Board of Surgery In-Training Exam (ABSITE) - The American Board of Surgery administers a yearly in-training examination which tests clinical and basic science knowledge. All residents and interns participating in general surgery programs are required to take this examination. At WBAMC a satisfactory performance on this examination is required.

Reminder to the Residents

Reading and Study beyond the Core Curriculum is necessary and expected!

Teaching Conferences

The most important clinical teaching occurs at the clinical teaching conferences which deal with the presentation, management, surgery, post-operative care and complications of actual patients. At these conferences the theoretical and basic science principles learned through reading textbooks and journals are applied and discussed in the actual care of patients.

Morning Report (Every Morning at 6:45 AM)

The Resident SOD presents all admissions and consults from the previous evening and selected cases from the previous day as directed by staff. This includes the appropriate lab and x-ray data. These cases are then discussed by the staff and residents. The progress and disposition of all inpatients is recounted by each of the Ward Teams.

SICU Rounds

Following morning report, the ICU staff and ICU residents conduct SICU rounds and X-ray review. Here the progress, problems, and treatment plans of each ICU patient are presented in open forum. All pertinent inpatient X-ray studies are then reviewed. Residents gain insight into current status of each patient, the management strategy for every SICU patient and ultimately the broadest possible critical care experience during their five years of training.

Core Curriculum (Every Wednesday at 7:00 AM)

A weekly faculty moderated presentation/discussion covering basic science and core general surgery subjects. Interval testing is used to provide feedback for the residents and staff.

M & M Conference (Every Wednesday morning after lecture)

The morbidities and mortalities from the previous week are critically reviewed by the responsible operating surgeons in open forum. Cases with particular teaching value are more formally presented by a selected resident with a brief slide presentation (see M&M format). Pathology and autopsy results are essential to the discussion and must be known by the presenting resident.

Preop Conference (Every Wednesday morning)

All proposed elective surgical cases are presented in preop conference by the operating resident surgeon. The presenting surgeon must demonstrate a knowledge of the indications, pertinent diagnostic studies, patient history, physical exam, technical aspects of the surgery proposed and post-op care plan. Pertinent radiologic slides, old operation reports and any other data germane to the case will be present at Preop Conference for staff review. The staff member assigned to each case must be informed and the case discussed the night before Preop Conference.

Tumor Board (Every Wednesday afternoon)

A weekly multidisciplinary teaching conference open to the entire hospital staff reviews selected tumor cases. The patient presentation, diagnostic work-up, and pathology are reviewed and options for treatment to include surgery and multi-modality therapy are discussed.

Staff Ward Rounds

Attending surgeons conduct formal and informal weekly bedside teaching rounds with each of the respective ward teams. All levels of the residency from Medical Student to Chief Resident participate. Basic science topics and clinical management issues are incorporated in the discussions.

Journal Club (Twice monthly on Friday in lieu of morning report)

A journal article chosen in advance is discussed. One resident is chosen to lead the discussion on its content, merit, and clinical applicability.

Trauma Conference (Twice monthly on Friday in lieu of morning report)

This is a conference at which interesting trauma cases are reviewed. All members of the Department of Surgery and the Department of Emergency Medicine are invited. Cases which involve multiple services and involve complex management problems are preferred. Management of trauma patients in the urban environment as well as in the field is discussed.

Trauma QI

A monthly multidisciplinary meeting where trauma cases are presented and recommendations for improvement in trauma care, from pre-hospital to rehabilitation are discussed.