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Details

Comprehensive Core Curriculum Supplement

Introduction

This Colon and Rectal Surgery Fellowship program is one year in duration. Nine months are spent at the sponsoring institution, Trinity Health Ann Arbor Hospital and three months at the University of Michigan. This Colon and Rectal Surgery program provides the resident with a deep and broad academic and clinical training environment. Program highlights include:

  1. Curated Fellowship tailored to resident goals and objectives
  2. Enhanced Recovery Pathway
  3. Resident Clinic
  4. Preparation for practice operations and business management after graduation

Curated Fellowship

The Curated Fellowship concept was presented at the 2023 Association of Program Directors for Colon and Rectal Surgery Annual Meeting by Dr Shanker. As a result, the APDCRS Curated Fellowship Committee was implemented, and Dr Shanker was appointed as Chair.

The Curated Fellowship is a program infrastructure feature that inserts key elements into the fellowship year that may be unique to the individual fellow and may include scholarly activity, advocacy, and other professional development goals. Prior to arrival, the fellow is asked to set professional development goals in addition to clinical goals that will more effectively transition into the work force.

The plan is tailored to the fellow, may change over the course of the year, and is intended to best prepare the fellow transitioning to the next chapter following graduation. It includes well-being, diversity and inclusion, and avoiding burn out. Faculty are committed to role modeling these behaviors and Dr Shanker has been certified in Executive Coaching to lead the Coaching Project in our department to guide residents and fellows professional goal aspirations that allow optimum transitioning.

Faculty

The resident will have the opportunity to work with all faculty at both institutions. All faculty at both institutions participate in scholarly activity at a regional and national level and all participate in regional and national committees, thereby serving as resources for the aspiring colon and rectal surgery resident. Regional representation includes the Michigan Surgical Quality Collaborative, a 70-bed collaborative funded by Blue Cross Blue Shield of Michigan that provides a risk-adjusted database for quality improvement and research. We are very well represented at APDCRS (Robert Cleary is Past President), ASCRS (Samantha Hendren is Co-Chair of ASCRS Rectal Cancer Committee, other UM and Trinity faculty are leaders of and participants in several other ASCRS committees), SAGES, and others. Dr Chang Co-Chairs the ASCRS Speed Mentorship Course.

Outpatient Clinic

At Trinity Health Ann Arbor Hospital and the University of Michigan, the resident will work with busy Colon and Rectal surgeons with large clinical inpatient and outpatient volumes. The resident will have the opportunity to see and thoroughly evaluate patients before surgery in the on-campus clinic. The resident will be an integral part of the Enhanced Recovery Pathway Patient Safety and Quality Initiative, the first in the state of Michigan that went live in 2012. The resident will have the opportunity to closely follow postoperative patients, thereby ensuring continuity of care. The resident will have a resident-run clinic every Tuesday morning where patients are seen and scheduled by the resident with faculty assistance as needed. With progressive autonomy, the resident will increasingly lead the discussion with patients to include options, risks, and benefits in preparation for independent practice. Patients will evaluate this experience. Opportunities are plentiful for those residents interested in learning about the intricacies of a surgery clinic, including coding, proper documentation methods, RVUs, revenue generation, and practice development. The resident will be well prepared evaluating employment options. In addition, the resident will see colorectal cancer patients in the Multidisciplinary GI Cancer Clinic following the Multidisciplinary GI Cancer Conference. This experience will include gaining expertise in total neoadjuvant therapy and nonoperative “watch and wait” practices. The resident will have personal space with a desk and computer and will, in many ways, be treated as a member of the faculty in preparation for independence.

Inpatient Experience

The resident will make daily rounds on the dedicated colon and rectal surgery service with a team composed of general surgery residents, a dedicated colorectal PA, medical students, and PA students. The colon and rectal surgery resident leads the bedside discussion for those patients personally evaluated in consultation in the clinic, operating room, emergency room, or patient care units. The chief general surgery resident leads the bedside discussion for other patients on the service with the colon and rectal surgery resident serving as a guide, resource, junior attending, and valuable member of the team. The multidisciplinary enhanced recovery team meets every morning to discuss patient plans with attention to multimodal pain management, anticoagulation and discharge needs.

General surgery residents will staff ED patients with the colon and rectal surgery resident when on call in the evening. Faculty are available to staff consultations 24 hours a day.

Call

The colon and rectal surgery resident will take call one day a week and 2 weekends a month during the nine months at Trinity Health Ann Arbor Hospital. Call is taken from home. At night and on weekends, the Emergency Department general surgery resident will call the colon and rectal surgery resident first when on call. Decision-making for Emergency Department and patient care unit consults will be based on the Colon and Rectal Surgery Supervision Policy, the document of which is reviewed with the Program Director. The Colon and Rectal Surgery resident will faithfully log patient encounters appropriately on the ACGME Log Case System website on a daily basis and this is monitored on a weekly basis by the Program Director. Duty hour regulations are strictly adhered to, monitored 24/7, and evaluated monthly at the Surgery Education Committee Meeting.

Ambulatory (Outpatient) Surgery

The program at the Trinity Health Ann Arbor sponsoring institution includes extensive on-campus outpatient anorectal surgery experience. Here, the resident will participate in operations for a broad and comprehensive spectrum of anorectal disease including hemorrhoids, fissures, fistulas (fistulotomy, advancement flaps, LIFT procedures, plug procedures), pilonidal disease, and condyloma. This is detailed in the document entitled Competency-Based Assignment Goals and Objectives.

Colonoscopy

The resident will be well-trained in interventional colonoscopy, flexible and rigid sigmoidoscopy and anoscopy. There is an opportunity for anorectal ultrasound for interested residents. Most of the colonoscopy and much of the anorectal experience for the resident is at Trinity Health Ann Arbor. The focus during the 3 months at the University of Michigan is on complex pelvic surgery that includes J pouches and exenterations.

Main Operating Room

The operative experience in this residency program is broad and comprehensive. The resident will participate in open, laparoscopic, and robotic surgery for colon and rectal cancer, diverticulitis, lower gastrointestinal hemorrhage, chronic constipation, inflammatory bowel disease, rectal prolapse, retro rectal neoplasms, carcinoid and other neoplasms, and many other colorectal diseases at both Trinity Health Ann Arbor and the University of Michigan. The variety and complexity of cases are complimentary at both institutions. The Program Director assigns cases on a weekly basis, ensuring that operative needs are met with the Competency-Based Assignment and Objectives document as a guide. This program is somewhat unique because of the longstanding robotic experience since 2009. As a result of advanced robotic training, some of our residents are prepared to start a colon and rectal surgery robotics program upon completion of the residency year. The laparoscopic experience is comprehensive also, however, especially at the University of Michigan and includes the hand-assist approach. Operative skills for open, laparoscopic, and robotic surgery are mentored and evaluated with formative feedback over the course of the year. All cases are recorded and evaluated on C-SATS and available for immediate download and review. The resident receives progressive autonomy so that upon completion of the residency, the resident is more than capable of independently caring for and operating on patients with diseases of the colon, rectum, and anus.

Resident Education

The resident education program is characterized by a comprehensive curriculum distributed upon arrival and covers the entire 12 months and is focused on written and oral board preparation. Tuesday morning is devoted to resident education with didactic meetings that include ASCRS-U and other relevant resources. Structured video review is an important part of our educational process, and all operations are available for video download or online review using C-SATS.

Conferences

Orientation includes topics that cover ACGME colon and rectal surgery program requirements that are strictly adhered to. Previous residents have invested in ethics, medical journalism, and other domains central to their version of the curated fellowship. Each resident will attend a root cause analysis.

1) Grand Rounds

The resident will assimilate and appraise literature and present one Grand Rounds session during the spring. Grand Rounds and D&C conferences are on Thursday mornings at the University of Michigan.

Global 360-degree evaluations include those from:

2) Death and Complications Conference 

The resident will have the opportunity to present cases and participate in discussions of cases relevant to diseases of the colon, rectum, and anus. This is designed to increase the knowledge base and develop the ability to assimilate and appraise literature in a critical manner with attention to methodology, and to formulate alternate ideas, which may impact positive changes in practice. The resident is required to complete a practice-based improvement log regarding the case. It is reviewed with the resident by the Program Director. The practice-based improvement log form is filed permanently in the resident portfolio. This form includes Patient Data, the Effect of the Complication on the Patient’s Outcome, Which Factors Led to the Complication (unfamiliar surroundings, inappropriate help/support, patient condition, high-pressure environment, disease process, etc.), Operating Room Environment, and Non-Operating Room System Factors. These activities help the resident identify knowledge gaps. The resident is expected to use the knowledge gained to educate patients and their families, other health professionals, residents and students.

3) Colon and Rectal Surgery Didactic Seminars 

Weekly didactic and core subject conferences are designed to cover all relevant topics in colon and rectal surgery. These conferences are currently on Tuesday morning at Trinity Health Ann Arbor and Friday morning at the University of Michigan. They are based on the ASCRS text, but other relevant resources are utilized to maximize educational opportunities. The pelvic floor experience is comprehensive and includes clinic manometry and time with a pelvic floor physical therapist. The didactic learning experience at the University of Michigan is also comprehensive. Journal club is held 6-10 times per year, and some are joint efforts that include both institutions.

4) Multidisciplinary Cancer Conference

This weekly conference at both Trinity Health Ann Arbor and the University of Michigan is attended by pathology, radiation oncology, interventional radiology, medical oncology, gastroenterology, oncology nurse navigators, geneticist, and research navigator. The resident has the opportunity to present cases and participate in the multidisciplinary discussion of cancers of the colon, rectum, and anus. Pathologic histologic material and imaging studies are reviewed for each patient presented at this conference. Following this one-hour conference, patients discussed in this conference are seen in the Multidisciplinary Cancer clinic by all relevant disciplines. Neoadjuvant and adjuvant therapies and operative intervention are discussed at length and planned at this time. Our robust nonoperative (watch and wait) program was implemented in 2017 and our clinical complete response rate is 50.4%. Our oncology department is aligned with Mayo Clinic in the Alliance and our patients are therefore considered for all national studies. We were a major contributor to the PROSPECT randomized trial comparing chemotherapy vs standard neoadjuvant chemoradiation and more recently the JANUS trial for patients with locally advanced rectal cancer.

5) Multidisciplinary IBD Conference 

This conference is led by Dr Shanker and occurs every month and is attended by gastroenterology, radiology, pathology, and colon and rectal surgery faculty and residents. The resident will have the opportunity to present cases and participate in the multidisciplinary management of patients with complex IBD.

6) Multidisciplinary GI Oncology Workgroup 

This group meets quarterly to discuss outcomes data, recent innovations, and future plans. The National Cancer Institute (NCI) considers Trinity Health Ann Arbor a model Community Clinical Oncology Program (CCOP) and has funded our program since 1994. We are the lead institution in the Michigan Cancer Research Consortium, one of 50 programs nationwide. We are one of the top ten accruing CCOPs in the country, conducting hundreds of CCOP and pharmaceutical trials with 600 to 700 patients enrolled per year. Nationally, we partner with the Mayo Clinic through the American College of Surgeons Alliance. The resident will learn about planning and reviewing available national study protocols, as well as reviewing current and planning future technologies.

University of Michigan

The resident will spend 3 months at the University of Michigan during the academic year. This rotation is characterized by complex colorectal cases including J pouches and pelvic exenteration. The clinical service obligations are similar to Trinity Health with a higher ratio of complex patients.

Evaluations

The resident receives 360-degree formative feedback on a regular basis. Some of the tools used to evaluate the resident include Direct Observation, Global Assessment, Structured Case Discussion, Review of Patient Outcomes, Record/Chart Review, CARSEP Review, CARSITE Review, Mock Oral Exam, the Practice-Based Improvement Log, and the Technical Skills and Performance Evaluation.

Global 360-degree evaluations include those from:

  1. Colon and Rectal Surgery faculty (monthly)
  2. Medical and PA Students (monthly)
  3. Nursing (every 6 months)
  4. General Surgery residents (monthly)
  5. Self (every 6 months)
  6. Patients (quarterly)
  7. Program Director (quarterly to include Exit Interview)

The resident will evaluate the faculty and the program at 6 months and again upon completion of the program.

Meetings

The resident will attend the following meetings:

  1. American Society of Colon and Rectal Surgeons (ASCRS) 
    The resident will submit meritorious research mentored by faculty for presentation at this meeting. Often, this research will have been presented at the Trinity Health Ann Arbor Annual Research Forum and the Michigan Chapter ACS Meeting so that ASCRS will be the 3rd opportunity to present the same work.
  2. Board Preparation Meeting 
    The emphasis of this meeting is preparation for the Qualifying examination but sometimes the meeting is SAGES, especially if there is scholarly activity to present, or another meeting depending on the resident's needs.
  3. Osler Oral Board Preparation Course 
    Even though it is after you graduate, this course has a stellar reputation, and we pay for you to attend. It is often just before the Oral Certifying Exam.
  4. Colorectal Residents Cleveland Annual Career Course 
    We have been faculty at this meeting, and it is one of the educational highlights for the resident. Topics include how to prepare for a job interview, how to evaluate job opportunities, what to expect with first job opportunities and how to plan for them, and how to set and manage career goals. We also have a lot of fun. We address much of this in the curated fellowship tailored to resident aspirations and needs.
  5. Trinity Health Ann Arbor Annual Research Forum 
    This meeting is held in the spring. The resident is expected to present meritorious research at this meeting.
  6. Michigan Chapter of the American College of Surgeons 
    This meeting is held in the spring. The resident is expected to present meritorious research at this meeting.
  7. APDCRS Fellows Robotics Course 
    Amir Bastawrous MD (Swedish Medical Center Seattle) and Robert Cleary MD started this annual comprehensive robotics course for colon and rectal surgery residents in 2011. Fellows in all 66 programs are offered the opportunity to attend.

Scholarly Activity

The resident is provided with unique research opportunities. A research team including a statistician and advisor with expertise in Design and Methodology are intimately involved in all projects and meet weekly, mentoring the resident every step along the way from the conception of the research idea, to formulating the best methodology, to submitting to Research Committee and IRB proposals, to preparation for presentation at regional and national meetings, to submission for publication.

The hospital has a comprehensive quality improvement and research infrastructure that encourages and supports scholarly activity. The resident will meet regularly with a faculty mentor and statistician and have the opportunity for real-time education in statistics and methodology. This Research Department has been prolific in the publication of new literature. The colon and rectal surgery resident will have the opportunity to present meritorious work at a local research forum sponsored by Trinity Health Ann Arbor. In addition, the resident will present at other regional and national meetings, including the annual spring American Society of Colon and Rectal Surgeons Meeting and will be required to write a manuscript for publication with mentoring throughout the entire scholarly activity process. The resident is allotted a half day per week to work on scholarly activity.

Job Opportunities

All of our resident graduates have secured excellent job opportunities in university and private practice settings. The program director and assistant program director are prepared to start making calls and sending emails upon arrival. Our leadership positions in ASCRS, APDCRS, Residency Review Committee, and ABCRS have allowed us credibility with our contacts nationwide.

Conclusion

Upon completion of the program, the resident will be well prepared to apply the highest standards of patient care in any academic setting across the country. The resident will be well-versed in the management of all relevant diseases of the colon, rectum, and anus. We expect that patients will be genuinely fond of the resident and feel so strongly about the quality of resident care rendered that they would recommend family and friends. Our residents will be well-trained in the critical appraisal of current literature and aspire to contribute on a lifelong basis. Upon completion of training, we expect our residents to be effective and collegial providers in any academic community or university practice in the country.