Brigham and Women’s Hospital
General Surgery Residency
Curriculum
2007-2008
INTRODUCTION
The Accreditation Council for Graduate Medical Education (ACGME) has
introduced specific requirements which are now being adopted by the Residency Review
Committee (RRC) for Surgery. Specifically, they have identified a list of six areas of
competency expected of a surgical practitioner completing training. Each rotation is to
have its own written curriculum incorporating these competencies. This curriculum is to
be reviewed by the resident and a faculty mentor at the beginning of the rotation and then
the evaluation of the resident at the end of the rotation is expected to focus on these
competencies. In addition to the traditional system of evaluation by supervising faculty,
there appears to be a consensus that this should include input from multiple levels, the socalled “360º evaluation” by peers, nursing, PAs, and the patients.
Formalizing the process of assessing competency will ultimately be valuable if we
can accomplish this without detracting from an educational program that has produced
exceptionally well-trained surgeons. We hope to continue to distribute the more detailed
curriculum developed by the Association of Program Directors in Surgery (APDS). We
will also continue the current system of evaluation with several faculty and senior
residents evaluating each resident’s performance on each rotation using an internet-based
program.
In addition, to meet these requirements, we have developed this rotation-specific
curriculum focusing on the competencies. On each rotation, the resident will partner with
a single faculty mentor. For the PGY1s, mentors for each rotation will be assigned.
More senior residents should ask a faculty member with whom they are comfortable to
serve as mentor. They should meet relatively early in the rotation to discuss the
curriculum, assuring that the resident understands the goals and objectives. The
identified faculty member will then be asked to play particular attention to that resident’s
performance during his/her time on their service. In addition, they will elicit feedback
from other members of the team and from the patients. At the end of the rotation, the
faculty member and resident will meet and together discuss the evaluation. Completion of
these evaluations will be required to progress through the program.
This document includes a discussion of the program goals, scope, and objectives,
incorporating the competencies as defined by the ACGME. This includes some of the
general approaches that we are using to assure competency in each area. This is followed
by a written curriculum for each rotation organized around the clinical activities, but
including the competencies. The APDS Surgical Resident Curriculum, distributed to all
residents, covers many of these subjects in greater detail than is possible here. The
competencies and the APDS objectives are all encompassing and it is unrealistic to
expect any resident to completely master all the objectives listed for any given rotation.
In fact, there is considerable redundancy so that many of the rotations reference the same
units from the APDS document while others are referenced only in the initial discussion
of the competencies and apply to all rotations. For example, the Abdominal Surgery Unit
4.5 is referred to on each of the General Surgery rotations.
As the resident progresses through the program reviewing these objectives on
multiple occasions, he/she will eventually master them. Competency is a cumulative
process and, although some procedures are mastered technically at a junior level, it
requires the maturity of chief residency to deal with the unusual or complicated case.
The resident and mentor should chose a medical knowledge focus for each
rotation and then expect that the resident will try to master this particular area. For the
first two years, suggestions for this focus have been made, but this should be a decision
between the mentor and resident based on the resident’s perceived areas of weakness. By
the end of the second year the resident should have some exposure to each of the major
topics in general surgery. The objectives should not limit the resident’s reading and it is
possible that the resident may not have the opportunity to care for patients with one of the
specified diseases on that given rotation. In the final years it is expected that the resident
will have covered much of the material at least once and should begin to focus on areas
that he/she knows they have not mastered.
The curricula are followed by an evaluation form to be completed by the resident
and faculty mentor for each rotation. The evaluation form addresses the specific medical
knowledge focus but is designed to elicit more general comments on the resident’s
progress in each of the competencies. Finally, specific discussions of our policies on
Resident Supervision and Work Hours and Environment are appended.
PROGRAM EDUCATIONAL GOALS, SCOPE, AND OBJECTIVES
The defining goal of the Brigham and Women’s Hospital General Surgery
Residency Program is “to prepare the resident to function as a qualified practitioner of
surgery at the high level of performance expected of a board-certified specialist.” This
level of performance implies competence in patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice. The program includes both a preliminary
track (one to three years of training) and a categorical track (five or more years of clinical
training), preparing the graduate for either further specialty education and training and/or
the practice of clinical general surgery and/or a career in academic surgical teaching and
investigation. We continue to believe that a related goal of the Brigham and Women’s
Hospital General Surgery Residency is to train not only competent surgeons but also the
future leaders of surgery in whatever field the resident eventually chooses.
The scope of the program includes comprehensive training in the principal
components of general surgery: diseases of the head and neck, the breast, skin and soft
tissues, alimentary tract, abdomen, vascular system, endocrine system, the comprehensive
management of trauma and emergency operations, and surgical critical care. Additional
components include experience in preoperative, operative, and postoperative care in
cardiothoracic, pediatric, plastic, and transplant surgery and participation in the
management of patients with common problems in urology, gynecology, neurological
surgery, orthopedics, burns, and anesthesiology. There is also sufficient experience in the
emergency room and in intensive care units to enable residents to manage patients with
severe and complex illnesses and major injuries requiring critical care. The program also
provides the opportunity for residents to learn the in-depth fundamentals of basic science
as applied to clinical surgery. The residents perform a variety of endoscopic procedures
and have the opportunity to become familiar with evolving diagnostic and therapeutic
methods. Most residents also spend two years in research and all acquire experience in
research design, statistics, and critical review of the literature necessary for acquiring
skills for lifelong learning.
The objectives of the program relate these goals to the six required competencies.
Specifically, in the context of the defined scope of the program, residents should become
competent in:
1. Patient care
Requirements: Residents must become competent in providing preoperative, operative,
and postoperative patient care that is compassionate, appropriate, and effective for the
treatment of surgical disease. Surgical residents must demonstrate manual dexterity
appropriate for their training level and be able to develop and execute patient care plans.
They are expected to communicate effectively and demonstrate caring and respectful
behaviors when interacting with their patients and families. They should gather essential
and accurate information about their patients and make informed decisions about
diagnostic and therapeutic interventions based on patient information, preferences,
scientific evidence, and clinical judgement. They should develop and carry out patient
management plans, counsel and educate patients and their families, and use information
technology to support patient care decisions and education. They need to be able to work
with other health care professionals to provide patient-focused care.
Approach: This has been the predominant formal focus of training in general surgery.
We have developed a schedule, based on rotations to a variety of surgical services, which
permits residents to acquire technical skills and the ability to apply their knowledge to
development of patient care plans. The system is one of graduated responsibility in the
operating room and for patient care and decision making. Residents participate in the
preoperative, intraoperative, and postoperative care of patients with disorders
encompassing the entire breadth of general surgery. Appropriate patient care
(performance) objectives from the APDS Surgical Resident Curriculum are referenced in
the Specific objectives listed for each of the rotation curricula.
2. Medical knowledge
Requirements: Residents must acquire a body of medical knowledge about established
and evolving biomedical, clinical, and cognate (e.g. epidemiological and socialbehavioral) sciences and be able to apply this knowledge to patient care. Residents are
expected to learn not only clinical surgery but also the fundamentals of basic science as
applied to surgery, including but not limited to wound healing, hemostasis, hematologic
disorders, oncology, shock, circulatory physiology, surgical microbiology, respiratory
physiology, gastrointestinal physiology, genitourinary physiology, surgical
endocrinology, surgical nutrition, fluid and electrolyte management, metabolic response
to injury including burns, musculoskeletal biomechanics and physiology, immunobiology
and transplantation, applied surgical anatomy, and surgical pathology. Surgeons are
expected to critically evaluate and demonstrate knowledge of pertinent scientific
information.
Approach: Such knowledge is acquired through a range of activities including teaching
at the bedside and in the operating room, by individual reading and study, and through
the variety of teaching conferences offered by the BWH Department of Surgery,
including Service Conference, Grand Rounds, Curriculum Conference, Pizza Conference
and the case conferences available on each of the services. Residents are given the APDS
Surgical Resident Curriculum and Greenfield’s Surgery: Scientific Principles and
Practice at the beginning of residency. As this material is mastered, more senior residents
are expected to explore the surgical literature widely. The weekly Curriculum Conference
addresses each topic with a series of lectures and, at the end of each subject period,
generally every month, a session is devoted to questions and answers in a board review
fashion. During both the clinical rotations and the two-year research fellowship, they
learn to interpret the literature and evaluate new scientific developments. Appropriate
knowledge objectives from the APDS Surgical Resident Curriculum are referenced in the
Specific objectives listed for each of the rotation curricula. Basic science objectives are
covered by APDS Units 2.1-2.10 and should be referred to throughout the residency.
Residents are required to take the ABSite Exam each year to evaluate their successful
acquisition of such knowledge.
3. Practice-Based Learning and Improvement Requirements: Residents must be
competent in the investigation and evaluation of their own patient care, in the appraisal
and assimilation of scientific evidence, and in improvements of patient care.
Specifically, surgeons are expected to critique personal practice outcomes and
demonstrate recognition of the importance of lifelong learning in surgical practice. They
should facilitate the learning of students and other health professionals.
Approach: A variety of approaches throughout the residency promote such competence.
In particular, the residents are exposed to many different surgeons and each takes a
unique approach to the same problems, giving the resident the opportunity to learn from a
variety of practice patterns. The Service Conference, our Morbidity and Mortality
Conference, gives residents the opportunity to review their own care and that of others,
developing concrete plans to prevent adverse outcomes in the future. The resident’s
ability to learn from previous experience and mistakes is continuously evaluated and the
teaching staff clearly has the opportunity to observe the resident’s maturation as he/she
passes through the various services on multiple occasions during their training. This
competency is addressed on virtually every rotation. Appropriate specific objectives are
described in the APDS Surgical Resident Curriculum Units 7.1-7.5 and should be
referred to throughout the residency. Residents are generally made to feel that teaching
their more junior colleagues and medical students is an important part of their duties.
4. Interpersonal and Communication Skills
Requirements: Residents are expected to develop skills that result in effective
information exchange and teaming with patients, their families, and other health
professionals. Specifically residents are expected to learn to communicate effectively
with other health care professionals, counsel and educate patients and families, and
effectively document practice activities.
Approach: Clearly these are skills that are in fact are a part of our resident selection
process, although informally. However, they are refined as the residents progresses
through his training. Some of this is accomplished through observation of teaching
faculty and more senior residents and some through the experience of interacting with
patients, families, and other health professionals. On each rotation, such skills are
evaluated by the faculty, by other members of the team, and by patients and the feedback
from such evaluation is used to help in the further development of such skills.
5. Professionalism
Requirements: Residents should develop a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to diverse patient
populations. They are expected to maintain high standards of ethical behavior and
demonstrate a commitment to continuity of patient care and sensitivity to age, gender,
and culture of patients and other health professionals. They should demonstrate a
commitment to ethical principles pertaining to provision or withholding of care,
confidentiality, informed consent, and business practices.
Approach: Some of this is accomplished through observation of teaching faculty and
more senior residents and some through the experience of interacting with patients,
families, and other health professionals. Topics in ethics and professionalism are
addressed directly in the Partners Resident Orientation, through selected Grand Rounds
topics, and through a series of conferences sponsored by the Ethics Service under the
direction of Dr. Lynn Peterson, one of our general surgery teaching staff. In addition, Dr.
Peterson has organized a series of lectures as part of the Curriculum Conference. On
each rotation, such skills are evaluated by the faculty, by other members of the team, and
by patients and the feedback from such evaluation is used to help in the further
development of such skills. Appropriate specific objectives are described in the APDS
Surgical Resident Curriculum Unit 7.4 and should be referred to throughout the
residency.
6. Systems-Based Practice
Requirements: Residents will demonstrate an awareness of and response to the larger
system of healthcare and effectively call on system resources to provide optimal care.
They are expected to practice high quality, cost-effective patient care, demonstrate a
knowledge of risk-benefit analysis, and demonstrate an understanding of the role of
different specialists and other health care professionals in overall patient management.
Approach: Systems-based practice is learned throughout the residency through a variety
of venues. Residents are exposed to faculty at BWH and the Faulkner hospital who
practice in both academic and private settings and as part of a HMO-type medical
practice, Harvard Vanguard Medical Associates. Likewise, at both BWH and the VA,
they have work with surgeons involved in the care of both private practice and indigent
patients. They also receive a range of didactic instruction on these subjects, including, for
example, a yearly Grand Rounds on coding and the BWH hospital-wide monthly topics
in quality improvement. On each rotation, such skills are evaluated by the faculty, by
other members of the team, and by patients and the feedback from such evaluation is used
to help in the further development of such skills. Appropriate specific objectives are
described in the APDS Surgical Resident Curriculum Units 7.1 and 7.5 and should be
referred to throughout the residency.
Cardiac Surgery Service Curriculum
PGY1:
Rationale for this rotation: The Cardiac Service is responsible for the care of patients
at BWH with a wide range of disease of the heart and great vessels. Cardiac surgery
represents one of the additional components of surgery that must be encompassed by the
training program including clinical experience in the preoperative, operative, and
postoperative care of such patients, according to the RRC requirements. Exposure to the
unique perspective provided by this rotation strengthens the resident’s knowledge,
experience, and overall competence in this arena.
Goals: To gain exposure to and become competent in the preoperative, operative, and
postoperative management of patients undergoing cardiac surgery. Although the PGY1
will participate in a variety of operations on the service, the major focus of this rotation
for the PGY1 should be to begin to participate and become competent in the perioperative
care of patients undergoing cardiac surgery. In addition to caring for patients on the
cardiac surgery floors, the PGY1 will cover patients in the Cardiac Surgery ICU.
Specific objectives: For patient care and medical knowledge competencies, see
Knowledge and Performance Objectives Unit 5.11 of the APDS Surgical Resident
Curriculum. Although the resident will be exposed to and have the opportunity to learn
about a variety of conditions on this rotation, the major focus for the PGY1’s medical
knowledge objectives on this service should be the perioperative care of patients
undergoing cardiac surgery and acquired and congenital cardiac disease. For practicebased learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice competencies, see Junior level knowledge
and performance objectives referenced in the program objectives p. 6-8 above. To
accomplish these competency-based objectives, the PGY1 should:
 Perform history and physical examination and share information with the senior
resident, fellow, and/or attending.
 Use available information, in combination with the interpretation of basic laboratory
and radiographic data, to develop a plan for the preoperative preparation of the patient
and discuss this with the senior resident/fellow/attending.
 Understand the basic pathophysiologic disease process and its surgical implications.
 Understand the basics of the surgical procedure performed.
 Develop a plan for the postoperative care of the patient with the senior
resident/fellow/attending.
 Provide the day to day care of patients on the service.
 Teach and help to supervise medical students on the service.
 Develop interpersonal skills for dealing with patients and other members of the health
care team.
 Master the basic science principles impacting the care of patients on the service.
 Learn basic surgical skills.
 Develop skills in practice-based learning and systems based practice as described in
p. 6-8.


Become comfortable with minor invasive procedures such as central line placement,
chest tube placement, arterial line placement, etc.
Become more familiar with invasive monitoring/diagnostic/therapeutic tools such as
pacemakers, IABPs, pulmonary artery catheters, vasoactive medications, etc.
These learning objectives and expectations should be reviewed with the faculty mentor at
the beginning of the rotation.
Educational content: The patient population will consist of males and females from a
mix of ethnic and socioeconomic groups, from 20’s through the elderly Patients will
include new referrals from primary physicians and cardiologists, and patients referred
from the emergency ward or as inpatient consults. In addition, some patients will be seen
in follow-up. The resident will be expected on average to follow 10-20 inpatients,
participate in up to 5 surgeries per day, and see 5-10 patients on clinic days. The resident
should see patients in the Cardiac Surgery Clinic with the attending of the service one
day a week.
Teaching methods: Faculty, fellow, and senior resident precepting will be provided on
the floors, in the OR, and in the clinic. In addition to the regular teaching conferences of
the Department, the resident is expected to try to attend the conferences of the Cardiac
Surgery Service.
Ancillary educational materials: The resident should read and understand the
appropriate sections of the APDS Surgical Resident Curriculum (Junior level Knowledge
and Performance Objectives Unit 5.11). Appropriate chapters in the Greenfield textbook
and any of the surgical atlases should be used to accomplish these objectives.
Evaluations methods: In addition to the New Innovations Evaluations by multiple
faculty and of the rotation by the resident, the resident will, in conjunction with his/her
faculty mentor, evaluate both his/her performance and the rotation with the
accompanying form.
Strengths and Limitations: The diversity of clinical materials should provide an
exceptional experience in the care of a variety of patients undergoing a variety of cardiac
procedures. The complexity of cardiac ICU care should provide an excellent introduction
to intensive level surgical care and management of complex cardiopulmonary
pathophysiology. The complexity of the operative procedures and the work load
somewhat limit the PGY1’s operative experience.
Residents and faculty are involved in creating and revising this document. Updated
by Dr. Jennifer Rabaglia 2006.
PGY2:
Rationale for this rotation: The Cardiac Service is responsible for the care of patients
at BWH with a wide range of disease of the heart and great vessels. Cardiac surgery
represents one of the additional components of surgery that must be encompassed by the
training program including clinical experience in the preoperative, operative, and
postoperative care of such patients, according to the RRC requirements. Exposure to the
unique perspective provided by this rotation strengthens the resident’s knowledge,
experience, and overall competence in this arena.
Goals: To become more competent in the preoperative, operative, and postoperative
management of patients undergoing cardiac surgery. In comparison to the PGY 1 level,
the PGY2 will participate more meaningfully in a wide variety of operations and
procedures on the service. However, the major focus of this rotation remains to further
the resident’s competency in the perioperative care of patients undergoing cardiac
surgery. In addition to caring for patients on the cardiac surgery floors and in the Cardiac
Surgery ICU, the PGY 2 may sometimes see new consults to the service.
Specific objectives: For patient care and medical knowledge competencies, see
Knowledge and Performance Objectives Unit 5.11 of the APDS Surgical Resident
Curriculum. Although the resident will be exposed to and have the opportunity to learn
about a variety of conditions on this rotation, the major focus for the PGY2’s medical
knowledge objectives on this service, in comparison to the PGY 1 role, should be to
develop a more advanced level of competency in perioperative care of patients
undergoing cardiac surgery and acquired and congenital cardiac disease. For practicebased learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice competencies, see Junior level knowledge
and performance objectives referenced in the program objectives p. 6-8 above. To
accomplish these competency-based objectives, the PGY2 should:
 Perform history and physical examination and share information with the senior
resident, fellow, and/or attending.
 Use available information, in combination with the interpretation of basic laboratory
and radiographic data, to develop a plan for the preoperative preparation of the patient
and discuss this with the senior resident/fellow/attending.
 Understand the basic pathophysiologic disease process and its surgical implications.
 Understand the basics of the surgical procedure performed.
 Develop a plan for the postoperative care of the patient with the senior
resident/fellow/attending.
 Provide the day to day care of patients on the service.
 Teach and help to supervise medical students and PGY 1’s on the service.
 Develop interpersonal skills for dealing with patients and other members of the health
care team.
 Master the basic science principles impacting the care of patients on the service.
 Learn basic surgical skills.



Develop skills in practice-based learning and systems based practice as described in
p. 6-8.
Become proficient with invasive monitoring techniques and minor invasive
procedures (central line placement, thoracostomy tube placement, arterial line
placement, occasionally even balloon pump placement)
Become more proficient with the use and management of vasoactive
medications/drips in the acute postoperative period.
These learning objectives and expectations should be reviewed with the faculty mentor at
the beginning of the rotation.
Educational content: The patient population will consist of males and females from a
mix of ethnic and socioeconomic groups, from 20’s through the elderly Patients will
include new referrals from primary physicians and cardiologists, and patients referred
from the emergency ward or as inpatient consults. In addition, some patients will be seen
in follow-up. The resident will be expected on average to follow 10-20 inpatients,
participate in up to 5 surgeries per day, and see 5-10 patients on clinic days. The resident
should see patients in the Cardiac Surgery Clinic with the attending of the service one
day a week.
Teaching methods: Faculty, fellow, and senior resident precepting will be provided on
the floors, in the OR, and in the clinic. In addition to the regular teaching conferences of
the Department, the resident is expected to try to attend the conferences of the Cardiac
Surgery Service.
Ancillary educational materials: The resident should read and understand the
appropriate sections of the APDS Surgical Resident Curriculum (Junior level Knowledge
and Performance Objectives Unit 5.11). Appropriate chapters in the Greenfield textbook
and any of the surgical atlases should be used to accomplish these objectives.
Evaluations methods: In addition to the New Innovations Evaluations by multiple
faculty and of the rotation by the resident, the resident will, in conjunction with his/her
faculty mentor, evaluate both his/her performance and the rotation with the
accompanying form.
Strengths and Limitations: The diversity of clinical materials as well as the continued
exposure to complex, highly acute cardiopulmonary pathophysiology should provide an
exceptional experience in the care of a variety of patients undergoing a variety of cardiac
procedures. The complexity of the operative procedures and the work load somewhat
limit the PGY2’s operative experience.
Residents and faculty are involved in creating and revising this document. Updated
by Dr. Jennifer Rabaglia 2006.