Mercy Catholic Medical Center Surgical Residency Program
Surgery Resident Evaluation Form (PGY V)
Resident:
Rotation: General Surgery
Name of Evaluator:
Rotation Evaluation Dates:
Mercy Fitzgerald
MHOP
Please evaluate the above resident on the basis of performance during this specific rotation. Rank each
resident on a 1-5 scale with 5 being the highest. In general, a “1” would be unsatisfactory, the average
resident is a “3”. If there is inadequate information, please check “not applicable”.
General:
Evaluation (1-5):
Not Applicable:
1.
2.
3.
4.
5.
Initiative, self-motivated.
Dependability, can be counted on to complete tasks.
Interacts well with patient and staff.
Self-confident but will seek help from others.
Teaching of medical students.
Please place check in appropriate box:
Knowledgeable
COGNITIVE KNOWLEDGE:
Demonstrates understanding of the
basic science foundation of the
specialty
Knowledgeable
and Able To
Teach
Learning But
Incomplete
Absent or
Inadequate
A) Physiology, fluid and electrolytes.
B) Pathology of inflammatory and
malignant disease.
C) Infectious disease.
D) Pharmacology and nutrition.
Please place check in appropriate box:
Knowledgeable,
CLINICAL PERFORMANCE:
Confident and
Effective
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
E) Able to completely coordinate the
care of the patient in the outpatient
setting.
F) Able to direct the care of multiple
pre- and post-operative patients.
G) Understands and is able to apply
the principles of surgical critical
care.
H) Understands all operative
approaches to a surgical or vascular
problem and is able to pick the most
appropriate.
Please place check in appropriate box:
Knowledgeable,
OPERATIVE ABILITIES:
Confident and
Effective
I) Generally facile with laparoscopic
approaches for advanced
laparoscopic procedures.
Understands principles of stapling
devices
J) Understands the principles of
gastrointestinal and/or vascular
anastamosis.
K) Understand and manages
intraoperative emergencies (ie.,
bleeding, enterotomy).
Please place check in appropriate box:
Knowledgeable,
OPERATIVE PERFORMANCE:
Confident and
Effective
Knowledgeable,
But Not
Independent
Learning But
Below
Expectations
Unsatisfactory
L) Able to direct the operative team
effectively. Able to use assistants
well.
M) Able to provide exposure in difficult
procedures.
Based on the experience in this rotation do you think the resident would be able to:
Please place check in appropriate box:
Independent,
Confident,
Effective and
Safe
Needs
Direction, But
Understands
Principles
Needs Much
Assistance
N) Perform a thryroidectomy and parathyroidectomy … or
… perform a total gastrectomy.
O) Perform a laparoscopic hernia … or … perform a total
colectomy.
P) Provide critical care to the sickest patient that you
have seen.
Q) Perform a fem-pop bypass … or … evaluate a
perforated diverticulitis and perform the appropriate
procedure.
R) Evaluate a pancreatic mass and, if necessary, perform
a pancreaticoduodenectomy … or … perform an AP
resection.
S) Interact appropriately with multiple consultants, ED
physicians and nursing staff.
T). Discuss complex surgical problems and prognosis
with patient and family.
Overall Evaluation (Compare with the last 10 resident at this level on this rotation):
Please place check in appropriate box:
Top 20%
Middle 60%
Lower 20%
Do you think this resident should be allowed to complete the residency?
Yes____ No____ Needs more evaluation____
Do you think this resident would successfully pass both Part I and II of the Boards?
Part I? Yes_____ No_____
Part II? Yes______ No_____
Comments:
Signed:
Date:
Please return the completed form to Program Director, MCMC General Surgery
Residency Program, 1500 Lansdowne Ave, Darby, PA 19023 . Thank you for your assistance. Rev 6/00
No