Year I

Before starting their clinical rotations, first year residents must take and pass courses in Advanced Trauma Life Support and Advanced Cardiac Life Support. During the first year, residents must also take and pass the Fundamental Critical Care Support. The emphasis during the first year is on history and physical examination, preoperative care, outpatient care, postoperative care, interpersonal and communication skills, and professionalism. During the first three months of residency, residents are required to attend a series of core orientation lectures. These include lectures on clinical management of basic problems encountered in medical and surgical patients. Included in this series are lectures on ethical, socioeconomic and medicolegal problems. In addition to the everyday care of patients, first year residents are expected to learn how to place Swan Ganz catheters, central lines, arterial lines, and chest tubes, remove venous and arterial lines, incise and drain small abscesses, and close wounds and lacerations. They also perform some outpatient surgery, such as lumpectomies, biopsies, simple wound closures, straightforward bronchoscopies, proctosigmoidoscopies, and some critical care. In addition, they often serve as second assistants in the operating room.

The rotations for first year residents include four to five months on general surgical services, two to three months on vascular surgery, and one month of surgical oncology, trauma/critical care surgery, the emergency department, neurosurgery and plastic surgery. At the end of the first year, the resident should be able to care for patients as their most important responsibility. They should be able to present data obtained from a comprehensive history and physical examination in both an oral and written manner. They should demonstrate competency in performing certain selective invasive and therapeutic procedures, and show the proper use of sterile technique. They should be able to teach patients and their families about disease processes and the treatment plan. They should be able to provide cost effective health care. They should help to teach nurses, medical students, and other health care providers about disease processes. They will be taught to treat patients, physicians, and other medical personnel in a professional manner. They should develop plans for continued study, reading, and possible research projects, and they should be able to survey the surgical literature.

Year II

In the second year, residents are given more responsibility under appropriate supervision. Their duties include preoperative care, outpatient care, and postoperative care. They also serve as the first contact for emergency department and inpatient consults. They are given more responsibility for intensive care. During the second year, these residents also begin to coordinate some trauma resuscitations. They cover the transplant service and learn the problems of transplant rejection. Procedures, which are learned during the second year, include some cases of laparoscopy, proctoscopy, flexible sigmoidoscopy, endoscopy, downsize tracheostomies, colonoscopy, laryngoscopy, bronchoscopy, cholecystectomy, mastectomy, bowel resection, angio access, pyloromyotomy and the repair of hernias, both pediatric and adult. They also learn to administer local anesthesia and use intravenous sedation. Second year residents often function as first assistants in the operating room.

The rotations included in the second year include four months on the general surgical services, including bariatric surgery, hepatobiliary surgery, colon and rectal surgery and trauma surgery, three months on the transplant and pediatric surgery service, two months on the night float service, and one month each on the vascular surgery service, pediatric surgery service at Children's Hospital of Pittsburgh, and on the burn surgery service at West Penn Hospital.

By the end of the second year, the residents should be able to use scientific knowledge and research findings and apply it to the care of patients, understand the ethical aspects of surgical intervention, function in an effective, collaborative role with faculty, first year residents, and more senior level residents, function in a leadership role in talking to patients and families, demonstrate the development of cost consciousness as it pertains to medical care, teach and direct first year residents and medical students, as well as nurses, in the management of surgical patients, and demonstrate progress toward the achievement of professionalism, personal maturity, surgical judgement, and surgical knowledge.

If not achieved during the first year, then during the second year, all residents will be required to develop a research project with a mentor. The hospital requires that all residents and faculty participating in research must attend a series of lectures, complete a computer-based program and pass a test demonstrating an understanding of the principles of institutional review for research, including ethics, patient protection, confidentiality, the use of animals, and integrity of the research. After completing the Institutional Review requirement, the residents will be expected to develop a hypothesis, develop a plan to check the hypothesis, record the results, and draw conclusions. Upon completion of the research, each resident will be expected to present the research formally to their peers, faculty, and external judges. Each presentation must be formal and computer technology must be used. Residents with excellent research projects will be encouraged to present their results regionally and nationally and to publish their results in peer-reviewed journals. In addition to the resident-wide research requirement for second-year residents, there is a requirement for research in the third or fourth year. Thus, over the course of the first four years of the residency, three research projects are to be presented. Research projects involving the results of a clinical series will be used to teach practice-based learning and improvement.

Year III

In the third year, the residents are given increasing responsibility. In this year, they have more responsibility for preoperative and outpatient care, as well as postoperative care. They also have more responsibilities in the intensive care unit and trauma resuscitations. They serve as first contact for emergency room and inpatient consult and gain experience in cardiac surgery. They also first assist on major general surgery cases and open heart procedures. Residents learn the techniques of vascular anastomoses, upper endoscopy, colonoscopy, bronchoscopy, breast lumpectomy and axillary dissection, bowel resection, laparoscopic cholecystectomy, splenectomy, and incisional hernia repair. In addition, they become familiar with the fine needle aspiration of breast masses, stereotactic breast biopsy, and the use of ultrasound.

Rotations included in the third year are six months of general surgery, including colon and rectal surgery, breast surgery, minimally invasive surgery, bariatric surgery, and hepatobiliary surgery, two months of vascular surgery, three months of cardiac surgery, and one month on the Night Float Service.

By the end of the third year of residency, each resident should be able to manage patients having complicated surgical problems, act as a first assistant in more complicated surgical interventions, use critical thinking in making decisions about patient care, incorporate ethical concepts in the care of surgical patients, cooperate with patients and families in planning operative procedures and postoperative care, teach junior residents and ancillary personnel concepts of disease and surgical care, understand the cost involved in surgical care, increase knowledge base by using computers and the surgical literature, increase technical skills, and show improved surgical judgement. They will understand and use practice-based learning and improvement, fine tune their interpersonal and communication skills, and act in a professional manner.

Research Year

One of the four categorical residents will spend one year doing surgical research. All residents performing research at Allegheny General Hospital must attend a series of lectures and pass an examination concerning the role and importance of the Institutional Review Board in research. The purpose of this year is to understand the value of research in the clinical practice of surgery, to be able to critically review and analyze surgical literature, to understand the ethical issues involved with surgical research, to understand the risks and benefits associated with research, to be involved with protocols for studies involving patients, developing and obtaining informed consent for randomization, understand and apply patient confidentiality, to use animal models, to practice integrity in research methodology and reporting, to demonstrate the ability to use computer technology, and prepare documentation for a small grant application, Institutional Review Board application, and status reports. Thus, by the end of the year, the resident should be able to draft a surgical research proposal, record surgical research data, analyze surgical research using the appropriate statistical methodology, report the results of surgical research, both locally and nationally, write abstracts of surgical research, and to write journal articles for publication.

Year IV

Residents in the fourth year are given senior level responsibility. They are expected to lead and coordinate resident coverage for their own surgical service. Coordinating the trauma/critical care service is the most important responsibility of the fourth year. They oversee the preoperative, outpatient, and postoperative care of surgical patients by junior house staff. They have increased responsibility for the overall intensive care unit care and manage complex trauma coordinating the care of patients with fractures, vascular and neurosurgical injuries, as well as chest, abdominal, and urologic trauma. Coordinating care of these complex patients is the most important tool for residents to learn systems-based practice.

Under direct attending supervision, fourth year residents are expected to perform major general surgery cases. Fourth year residents are expected to perform most major cases and to first assist only on more complex major surgical cases. During this year, they also perform thoracoscopy; pulmonary resection; esophageal resection; Nissen fundoplication; pancreatic, biliary, bariatric, and liver surgery, including resection. The techniques of bronchoscopy, upper endoscopy, mediastinoscopy, choledochoscopy, and laparoscopy are also developed. In addition to performing laparoscopic cholecystectomy, fourth year residents are exposed to advanced laparoscopic techniques, including bariatric surgery, bowel resection, hernia repair, and esophageal surgery. They are also exposed to the laser ablation of esophageal tumors, the use of ERCP, esophageal manometry, and ultrasound in trauma patients.

The rotations included in the fourth year are: Three months of daytime trauma and three months of night float, general surgery/trauma, three months of thoracic surgery, and three months of general surgery, including basic and advanced laparoscopic surgery.

By the end of the fourth year, the resident should be able to perform complex surgery under appropriate supervision, to provide complete follow-up care until the patient is fully recovered, assist junior residents in assuming, planning, and managing preoperative and postoperative care for patients with common surgical disorders, to guide junior residents in making decisions about preoperative and postoperative care, incorporate ethical principles in the daily practice of surgery, to cooperate and collaborate with other residents, faculty, and health care professionals to provide comprehensive health care for patients, to teach nurses, medical students, and junior residents, to demonstrate an understanding of the impact of health care legislation, Medicare, Medicaid, and third-party payment systems on the cost of surgical care for patients, and to demonstrate increased technical ability and improvement in surgical judgement, maturity, professionalism, and interpersonal skills. By presenting at Mortality and Morbidity Conference, residents learn practice-based improvement and communication skills.

Year V

The fifth year is the Chief year and is devoted entirely to the principle components of general surgery. Chief residents run their own general surgery services with the close cooperation of the attending staff. They are responsible for all of the care on their general surgery service, including preoperative care, outpatient care, intensive care unit care, and postoperative care. They are also responsible for operating room coverage. In addition, chief residents have administrative responsibilities for scheduling resident rotations, conferences, and vacations. They schedule Grand Rounds and arrange for Visiting Professors. For three months, they run the Ward Service in which they see and coordinate the care of their own patients preoperatively, manage the operative case and then follow the patients postoperatively.

With supervision, Chief Residents are expected to perform almost all major cases involving the head and neck, endocrine system, liver, pancreas, breast, biliary tract, vascular system, and surgical oncology. They learn the technique of resection of soft tissue tumors, the use of the gastrointestinal physiology as it pertains to the colorectal system, and the techniques of laparoscopic colon resection, and bariatric surgery. They also are expected to help teach junior residents biopsy techniques, herniorrhaphy, and some cases of cholecystectomy. During the Chief year, they gain experience in vascular ultrasound and interventional vascular radiology.

Rotations included in the fifth year are six months covering the general surgery services, three months covering the ward general surgery service, and three months covering the vascular service.

At the end of the fifth year and at the end of the surgical residency, the residents should be able to demonstrate a high level of scientific, clinical, and technical knowledge, skillfully perform operative procedures, demonstrate effective decision making and clinical judgement in the management and care of all types of surgical patients, evaluate the cost effectiveness of patient care, demonstrate and understand the collaborative role of the surgeon and the consultative nature of the surgeon in the practice of surgery in the community, supervise junior residents in caring for patients with complex surgical conditions, understand the ethical issues involved in surgical practice, evaluate the teaching skills and clinical skills of junior residents and provide guidance for improving those skills, understand and use computers and the surgical literature to care for patients. Chief Residents accept administrative responsibility and accept the value of lifelong learning as a necessary prerequisite to maintaining surgical skills and knowledge. They demonstrate the surgical judgement, technical skill, and maturity necessary to be an independent operating surgeon.

During five clinical years of a surgical residency, each resident will be expected to have learned the competencies of: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice.

On graduation, the resident should be able to function as an independent and highly-competent practitioner of general surgery and become Board Certified in the specialty of surgery.