Education Coordinator: Dr. Stephanie Tung (stephanie.tung@nygh.on.ca) and Dr. Natalya Zhang (natalya.zhang@nygh.on.ca)
Site/Medical Education Administrative Assistant: Sharita Wimalanathan sharita.wimalanathan@nygh.on.ca
Welcome to General Surgery at North York General Hospital! As a trainee in Family Medicine, the main objective of this rotation is to gain comfort with common general surgery problems. You will diagnose and understand management pathways for surgical issues which are encountered regularly by first-line GPs in the office, walk-in clinic, and/or emergency room.
Please see the comprehensive list of objectives for this rotation below.
Your weekday mornings usually begin at 7am where you form an important part of the Acute Care Surgery (ACS) service. You will be working with a different attending General Surgeon every week. The objective here will be recognizing, assessing, and managing urgent surgical issues and complications, both in the emergency department and on the ward. Another objective will be understanding safe and early transition to outpatient care in the community. The weekday mornings include an Acute Care Surgery clinic at 10am where common ambulatory issues are seen. It is desirable for you to attend this ACS clinic contingent on workflow and discussion with ACS team members. If you are not able to attend this clinic regularly in your first week of service, please inform your supervisor early in the second week of your rotation.
Your afternoons will have you taking first-call for Acute Care Surgery until 5pm, following up on test results, and managing ward issues. The surgery staff and surgical resident are often scrubbed in surgery during this time, but remain available to discuss any questions or concerns. During your rotation, you will be scheduled to attend two afternoon General Surgery outpatient clinics to gain exposure to non-emergency surgical issues (Breast Diagnostic Centre and a clinic focused on Abdominal wall hernias). A list of objectives for these general surgery clinics is found in Appendix 3 – please review prior to attending clinics. When you are scheduled to be in clinic, request staff or surgery resident to take first-call until 4pm, at which point you should return to the ACS service to wrap up your day as usual. Quiet afternoons as first-call can also be used as an opportunity to assist in Surgery or observe Endoscopy.
Prior to going home, you should touch base with your ACS attending and/or surgical resident to review consults and update the team on routine ward issues. It is helpful to start preparing anticipated discharges for the following day if workflow permits and it’s not too late.
You will be asked to take call 1 weekday per week, and 1 weekend (Saturday / Sunday) per month. Your on-call dates will generally be available 1 to 2 weeks before the start of your rotation. Weekday call is from 5pm to 10pm, with the expectation that you will be signed over and leaving hospital by 11pm. Weekend call is from 7am to 11pm.
If your family medicine clinic half-day is scheduled in the morning time-slot, you are requested to shift your FM clinic into the afternoon timeslot if this is an option based on discussion with your FM preceptor. Daily participation with the ACS team in the morning (except for Wednesday morning academic half day) ensures optimal team function and an optimal educational experience, however this shift must not be made if it adversely impacts your family medicine obligations.
We would like you to select a surgical topic-of-interest to read around during your rotation. Alternatively, you can present an interesting case from the ward and read around it. Please discuss potential topics with your supervisor early in your rotation. You will present to your supervisor or to the General Surgery group midway through your rotation.
Dr. Stephanie Tung (stephanie.tung@nygh.on.ca) will be your primary supervisor. If she is away, you will receive an automatic reply directing you to an interim supervisor. There are 12+ general surgeons at NYGH (for a current list, visit https://www.nygh.on.ca/areas-care/surgery/surgical-specialties/general-surgery?cid=1356&lang=1), and you will have a chance to interact with many of them. You are usually sent an email in regards to setting up an orientation with Dr. Tung, Dr. Zhang, and/or Dr. Jain before the rotation or within the first week of the rotation. At the midway point and end of the rotation, Dr. Jain may want to speak with you in regards to a "mid-point" and "exit" interview to see how the rotation is serving your needs. Your interim and final evaluations will be based on feedback received from staff and team members you work with during your rotation.
Our team of surgeons tries hard to understand your learning objectives as trainees in Family Medicine. Our goal in designing this rotation is to ensure you come out confident and skilled to manage acute and/or complex patients in your practice. We appreciate your honest and ongoing feedback to make this rotation a strong and rewarding learning experience for you and your colleagues.
General Surgery (Year 1) Essential Competencies, as provided by NYGH Family Medicine Program Director in 2019
SRG01. Utilize the competencies of a family physician when addressing surgical issues.
FAM14. Interpret the test results promptly and correctly.
FAM15. Communicate test results to the patient in a timely fashion.
FAM16. Develop and implement an appropriate treatment plan.
FAM18. Document appropriately in the chart.
FAM2. Take an appropriately thorough history in a timely manner.
FAM22. Demonstrate commitment to patients, colleagues, profession and society through ethical and reflective practice.
FAM3. Display effective, professional and non-judgmental communication skills.
FAM4. Adopt a patient centered approach.
FAM5. Perform an appropriately thorough physical examination in a timely manner.
FAM6. Construct an appropriately thorough differential diagnosis related to common symptoms that is congruent with the data generated by the history and physical and weighted according to probability.
SRG02. Demonstrate an effective approach to patients presenting with surgical concerns.
2A. Perform appropriate pre-operative assessment identifying potential surgical risk (office).
2B. Facilitate referral prior to surgery when risks identified (office).
2C. Participate effectively when assisting in the Operating Room (in-hospital).
2D. Perform appropriate postoperative assessment through a focused history, physical examination and investigations (in-hospital).
2E. Initiate management of common postoperative complications (office / in-hospital).
SRG05. Demonstrate an effective approach to common gastrointestinal conditions.
5A. Initiate assessment of common gastrointestinal symptoms with appropriate history and physical exam.
5B. Propose appropriate investigations for common gastrointestinal symptoms.
5C. Diagnose common gastrointestinal conditions.
5D. Manage common gastrointestinal conditions including referral as necessary.
5E. Screen using available evidence through history, physical exam and investigations for common gastrointestinal malignancies.
5F. Perform: nasogastric tube insertion; fecal occult blood testing; incision and drainage of thrombosed external hemorrhoid; anoscopy/proctoscopy.
SRG09. Demonstrate an effective approach to diseases of the breast.
9A. Initiate assessment of common breast symptoms with appropriate history and physical exam.
9B. Detect breast lumps on breast examination.
9C. Investigate breast lumps appropriately.
9D. Identify patients at increased risk for breast cancer.
9E. Screen for breast cancer using available evidence through history, physical exam and investigations.
9F. Perform aspiration of breast cyst.
Understand surgical assessment of a patient (i.e. what happens after a referral is sent)
Recognize normal and abnormal post-operative recovery (inpatient and outpatient)
Gain competency in resuscitation, workup, and initial management of surgical emergency patients
Assessing pre-operative risk for surgery; medical optimization for surgery
Develop an approach to acute pain/post-operative pain management
Appreciate elements of an informed consent
Gain familiarity with common surgical procedures (endoscopy, hernia repair, cholecystectomy, appendectomy, mastectomy/lumpectomy, colon resection)
Become expert in the diagnosis and approach to the following:
Abdo Pain NYD
Inguinal/Ventral/Incisional hernias
Appendicitis
Diverticulitis
Peri-anal problems (hemorrhoids, fissures, abscess)
Gallstone Diseases
Bowel obstruction (Small vs. Large)
Abscess
Cancer (Colorectal & Breast)
Benign breast conditions, nipple discharge
GI Bleed/Rectal Bleed
Ischemic bowel
Differentiating between a wound infection and fascial dehiscence
Interpretation of abdominal x-rays
Anatomy of common General Surgery procedures (i.e. What's an Anterior Resection? What's the difference between an ileostomy and colostomy?)
Abdominal Exam
Breast Exam
Digital rectal Exam
Opening and packing a wound infection/abscess
Other learning objectives:
Suturing/Surgical Assisting
Inserting foley catheters/NG tubes
Does a newly diagnosed inguinal hernia, ventral hernia, or umbilical hernia require imaging prior to referral to a surgeon?
Groin pain with no palpable hernia: what is the differential diagnosis and workup? What if an ultrasound shows a small inguinal hernia which is not palpable?
Which hernias benefit from repair?
What are the risks of repairing an inguinal hernia? Ventral hernia?
What is the risk of recurrence after repair?
How to examine for an inguinal hernia, what are relevant findings to document?
How to examine a ventral hernia, what are relevant findings to document?
Current screening guidelines for average and high risk women
A focused history for breast complaints including an assessment of breast cancer risk factors
An approach to work-up of a palpable breast mass and nipple discharge
Understanding the pathology report and recognizing which benign, high risk and malignant lesions require specialist consultation
Demonstrate taking a focused history and performing a full breast and axillary examination