Surgery

Educational Supervisors:  

Dr. Stephanie Tung stephanie.tung@nygh.on.ca, Dr. Neelesh Jain neelesh.jain@nygh.on.ca, and/or Dr. Natalya Zhang natalya.zhang@nygh.on.ca 

Medical Education Administrative Assistant: 

Jordan Hoeller jordan.hoeller@nygh.on.ca  

Rotation Structure and Objectives 

During the surgery rotation at North York General Hospital, you will diagnose and manage surgical issues routinely encountered by family physicians in the office, walk-in-clinic, and/or emergency room.

 Learning objectives for Family Medicine trainees will be met through 2 concurrent streams:

1. Inpatient Care & Emergency Room Consultations, through the Acute Care Surgery (ACS) service

-You will gain experience in:

  i.      Surgical emergencies, including Abdo pain NYD, appendicitis, gallstone disease, diverticulitis, bowel obstruction, abscess, perianal disease, wound infection and other post-operative problems

  ii.      In-hospital care

  iii.      Emergency Medicine

  iv.      Care of the Elderly

  v.      Peri-op management, including resuscitation / informed consent / diabetes meds / anticoagulants / control of acute pain & nausea

    vi.      Optional: Surgical Assisting in the operating room

2. Outpatient Care

-You will participate in 3 General Surgery clinics:

 i.      ACS clinic = Outpatient management of urgent General Surgery conditions

   ii.      Breast Diagnostic Centre

  iii.      Abdominal wall hernia clinic

-You have the option of participating in 2 or 4 of the following “non-GenSurg clinics”, depending on the duration of your rotation:

2. 2. 1. 1. Prostate Centre (Urology) for family physicians

         2. Ophthalmology for family physicians

         3. Otolaryngology for family physicians

         4. Gastroenterology / Observing Endoscopy for family physicians

         5. Upper extremity / Hand disorders for family physicians (ie, under the domain of Plastic Surgery at NYGH) 

Please see the comprehensive list of objectives for surgical rotation below, based on DFCM Competency Based Curriculum, version 2023.  

Checklist: a few weeks before your rotation 

• Shift your weekly family practice clinic to afternoon for this rotation, if it is scheduled to be in the morning.  Joining the ACS team in the morning best allows meeting the educational objectives.  It also optimizes delivery of patient care and your integration with other ACS team members.

• Email Jordan jordan.hoeller@nygh.on.ca  your preferred optional outpatient clinics.  Rank them 1 to 5 (Urology, Ophthalmology, Otolaryngology, GI, Hand).  You should expect 2 optional clinics to be scheduled if you are on rotation for 3 weeks, and 4 optional clinics if you are on rotation for 4 weeks.   We will make every effort to schedule your preferred clinics, however there may be circumstances where this is not possible due to availability of clinics and/or staffing of the ACS service.  Please note that you may incur travel / parking costs to participate in optional clinics.   Residents can decline optional clinics and focus exclusively on General Surgery inpatient / outpatient learning opportunities.

Weekday routine 

During your time on General Surgery, you will form an important part of the Acute Care Surgery service. You will be working with two different attending General Surgeons every week. The ACS1 surgeon will be responsible for inpatient care and the ACS2 surgeon will be responsible for ACS clinic and new inpatient consultations some afternoons of the week. 

Morning Rounds 

Your weekday mornings usually begin around 7am where you will meet with the resident team to perform daily rounds. At 9AM, you will meet with the Allied Health team at our Multidisciplinary Care Rounds in the 5S Conference Room.

 Throughout the academic year, we usually have departmental teaching rounds Monday at 7am.  Information about these rounds is available via Chief Resident or your surgery supervisor.

After Rounds 

You will be taking first-call for Acute Care Surgery until 5pm, unless you are scheduled to go to clinic. During this time, you will be functioning as a hospitalist and taking new GenSurg consults. Never hesitate to find the ACS1 surgeon or resident in the operating room for questions, or review consults directly with the ACS2 surgeon when they are on-call. Quiet afternoons as first-call can also be used to observe & assist in Surgery, and/or to read resources related to outpatient clinics. 

Clinics 

You will receive an individualized clinic schedule prior to the start of your rotation.

 You will be scheduled for 5 surgical clinics if you are on-service for three weeks (3 GenSurg + 2 optional), and 7 clinics (3 GenSurg + 4 optional) if you are on-service for four weeks.

During clinic, you should re-assign your “first-call” responsibilities to either physician-assistant, medical student, resident, or attending staff surgeon (in discussion with other team members after morning rounds).

Prior to Going Home 

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. Do not start new consults after 4:30 pm. New work should be handed over to the on-call team instead. 

On-Call 

You will be asked to take call 1 weekday per week, and 2 weekend days (Saturday / Sunday) per month (these can be done on the same weekend or split across two weekends). Your on-call dates will generally be available 1 to 2 weeks before the start of your rotation, and are assigned by the Chief Surgical Resident. Weekday call is from 5pm to 10pm, with the expectation that you will be signed over and leaving hospital before 11 pm. Weekend call is from 7am to 10 pm. 

Your Supervisor 

Dr. Stephanie Tung (stephanie.tung@nygh.on.ca) or Dr. Neelesh Jain (neelesh.jain@nygh.on.ca) will be your primary supervisor. There are 14+ general surgeons at NYGH, and you will have a chance to interact with many of them. You will have an orientation meeting with Dr. Tung or Dr. Jain prior to the start of your rotation or during the first week of your rotation.

Your Evaluation 

Dates for interim and final meetings will be decided during your initial meeting. Your interim and final evaluations will be based on feedback received from staff and team members you work with during your rotation.

Absence reporting

Promptly report unscheduled absences to:

1. ACS staff, ACS surgical resident, and ACS Physician-Assistant

2. Your rotation supervisor

3. Sally Principio Sally.Principio@nygh.on.ca

In Conclusion 

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 surgical 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. 

Objectives based on UofT DFCM Competency Based Curriculum 2023

Entrustable Professional Activities in Family Medicine

FAM01. Understand the role of a generalist physician in the health care system.

1. 1A.  Appreciate how the knowledge, skills and attitudes of the generalist physician differ from the specialist physician.

2. 1B.  Provide continuity of care for a defined patient population and demonstrate

consistency as coordinator of patient’s care.

FAM02. Take an appropriately thorough history in a timely manner.

FAM03. Display effective, professional and non-judgmental communication skills.

FAM04. Adopt a patient centered approach.

FAM05. Perform an appropriately thorough physical examination in a timely manner.

FAM06. 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.

FAM07. Recognize the typical and atypical presentation of common diagnoses as well as possible emergent life-threatening disease.

1. 7A.  Identify emergent conditions that require immediate management or consultations

2. 7B.  Demonstrate appreciation of the unique considerations for recently hospitalized and/or post-operative patients.

FAM08. Demonstrate an effective approach to the presentation of undifferentiated symptoms / Medically Unexplained conditions.

FAM09. Demonstrate an effective approach to the presentation of acute self-limiting illness and potentially life threatening illness.

FAM12. Modify the differential diagnosis in light of unexpected or changing symptoms or when symptoms persist beyond what one would ordinarily expect.

FAM13. Justify selection of laboratory and imaging tests and employ them only when they would have an impact on patient management.

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.

FAM19. Participate effectively in collaborative practice, including appropriate referrals and consultations.

FAM20. Demonstrate an awareness of the need to become a lifelong learner.

FAM23. Demonstrate commitment to patients, colleagues, profession and society through ethical and reflective practice.

FAM24. Consider and apply ethical concepts as they relate to family medicine practice.

1. 24A.  Understand legal consent requirements.

2. 24B.  Facilitate informed consent discussions with patients or their substitute decision makers (SDM).

Care of the Elderly

COE01. Utilize the competencies of a family physician when addressing care of the elderly

COE05. Engage and collaborate with other health care providers appropriately in the health care system.

COE07. Demonstrate an effective approach to care of the elderly patient in hospital.

1. 7A.  Identify possible preventive strategies for hazards associated with hospitalization.

2. 7B.  Assess patient for these conditions on admission to hospital and on regular basis and institute corrective measures.

3. 7C.  Prepare a patient for discharge with consideration to these issues.

COE10. Manage medications in the elderly effectively.

Emergency Medicine

ER01. Utilize the competencies of a family physician in the Emergency Department

ER02. Demonstrate an effective approach to the presentation of potentially life threatening illness.

1. 2A.  Recognize the acutely ill patient.

2. 2B.  Initiate, with supervision, the stabilization of life-threatening conditions.

ER03. Take an appropriately thorough history in a timely manner in the Emergency Department.

ER04. Perform an appropriately thorough physical examination in a timely manner in the Emergency Department.

ER05. Justify selection of laboratory and imaging tests in the Emergency Department and employ them only when they would have an impact on patient management.

ER06. Construct an appropriately thorough differential diagnosis in the Emergency Department that is congruent with the data generated by the history and physical

ER07. Demonstrate an effective approach to the presentation of potentially emergent conditions in the Emergency Department.

ER08. Develop an appropriate treatment plan in the Emergency Department.

ER09. Document appropriately in the chart in the Emergency Department.

ER10. Engage other resources appropriately in the health care system in the Emergency Department.

ER11. Perform procedures independently in the Emergency Department

1. 11D.  Perform common procedures including nasogastric tube insertion, bladder catheterization, abscess I&D.

ER12. Perform procedures with supervision in the Emergency Department

12D. Demonstrate an understanding of the techniques used for needle thoracentesis and chest tube insertion.

ER13. Interpret the test results promptly and correctly in the Emergency Department

In-Hospital Care

HOS01. Performs an appropriate admission assessment
HOS02. Recognizes presentations that require critical care support
HOS04. Diagnoses and manages common inpatient presentations
HOS05. Recognizes deviations from common presentations and seeks appropriate assistance
HOS06. Identifies and takes preventive action to address hospital complications (delirium, pressure injury etc.)

HOS07. Interprets and responds to common investigations
HOS08. Conducts advanced care planning and documents appropriate goals of care
HOS09. Communicates diagnosis and treatment plan with patient and/or substitute decision maker
HOS10. Effectively documents hospital course and treatment plan in a timely fashion
HOS11. Summarizes information when communicating with colleagues, patients and families
HOS12. Recognizes indications for and collaborates with specialist and interprofessional colleagues
HOS13. Participates in interdisciplinary meetings such as case conferences, family meetings,

interdisciplinary health rounds etc
HOS14. Engage with primary care provider around the time of discharge to facilitate transition of care
HOS15. Effectively manages and triages time to meet urgent and non-urgent patient issues
HOS16. Advocates for patient needs in the hospital setting and through transitions of care
HOS17. Identifies opportunities to promote equity and serve marginalized populations
HOS18. Utilizes evidence-based resources to aid clinical decision making
HOS19. Recognizes own limitations and asks for help when needed
HOS21. Practices according to legal principles governing consent and capacity
HOS22. Demonstrates commitment to clinical duties while maintaining professional and personal boundaries

Men’s Health (Cis and Trans)/Health for People Assigned Male at Birth

AMAB02. Perform an appropriately thorough physical examination relating to the health of people assigned male at birth in a timely manner taking into account the patient life stage.

2A. Perform digital rectal examinations as indicated in a trauma-informed manner, using patient-centered anatomical terms.

Health Equity and Social Accountability

SA01. Apply principles of cultural safety, trauma-informed care, humility and reflective practice.

SA02. Appropriately integrate the components of person-centered care for people who belong to equity-seeking groups.

SA03. Navigate the complexities of financial and community resources to support patients’ needs.

SA04. Demonstrate cultural competency, humility, and allyship during a patient encounter.

SA05. Apply key conceptual frameworks to understand how power dynamics, societal and systemic health inequities, and determinants of health affect patient needs and care.

SA06. Engage in consistent self-reflection to understand how one’s situation in the world affects provision of patient care.