Prof. A.H.M.Shamsul Alam

Objective: Responses are measurable Structured: Responses are in uniform

format Practical: Practical aspects of Surgery This examination format focuses on

testing the practical skills of examinee while using diagnostic tools, laboratory data , procedural techniques and communication modes

Surgical pathology Specimen Illustration of pathological lesions

Diagnostic tools Images

▪ X-ray▪ CT scan/MRI

Data interpretation Communication skills

Verbal counseling Written Verbal Interactive( with colleagues)

Surgical skills (procedures)

This is to test your pathological background while you manage a surgical problem

Usually, a surgically removed specimen containing a pathological lesion is displayed

You need to Identifying the organ: see all around and look

evidences of surgery and read all the questions in the script- you will find the clues

Take your time and observe the morphology Describe methodically: organ> nature of

lesion> involved area> characteristics of lesion> surrounding tissue

1. Find three significant features in this pathological specimen

2. What is your gross pathological diagnosis?

3. What could be the possible presentation with such a lesion?

4. Mention diagnostic investigations for such a disease.

5. How do you stage this disease?

6. What are the principles of treating this disease?

1. Specimen colon shows two polypoidal mass and an ulcerative lesion. The ulcer has irregular and everted margin with a necrotic floor

2. Multiple colonic polyp and carcinoma colon3. Rectal bleeding, change of bowel habit, weight

loss, anaemia occurring in a middle or old age.4. Colonoscopy and biopsy- histopathology5. TNM or Duke’s classification depending on

tumour invasion of gut wall and surrounding tissue, nodal involvement and metastasis

6. Meso-vascular en-block resection of colon with at least 5cm of healthy margin

Tests your ability to use this diagnostic tools effectively and rationally

Images could be plain or contrast X-ray, CT or MRI

You need to Identify what type of image it is Take some time to appreciate the

abnormalities Find clues from the set questions in script Answer precisely

Scenario: A 70 year old man presented with recent weight loss and moderate degree of jaundice. As a part of diagnostic workup, an imaging study has been carried out. What kind of image it is?Mention four significant findings in the image. Mention the most probable image based diagnosis and two other differentials

Mention two advantages and two limitations of this investigation.

1. MRCP- Magnetic Resonance Cholangio Pancreatogram 2. Findings:

1. Dilated biliary tree up to the terminal end of common bile duct

2. No filling defect in biliary tree

3. Gall bladder distended

4. Pancreatic duct normal3. Carcinoma head of the pancreas.

4. D/D………………..

1. Periampullary carcinoma

2. Cholangio-carcinoma

3. Impacted calculus at the terminal end of CBD5. Advantages……….

1. Non-invasive investigation

2. Outlines whole biliary tree and pancreatic duct system for screening6. Disadvantage……

1. Not always precise in finding pathological changes(compared to ERCP)

2. Lacks therapeutic intervention

SCENARIO : This is the radiological image of chest ( PA view ) of a 50 year old man presented with significant weight loss and anorexia for four months .TASK Please read the radiological image carefully and answer the questions.1.List four significant findings in the image2.What is your radiological diagnosis?3.What organs / systems would you focus on during clinical evaluation of the patient?4.In absence of obvious clinical clue to have a diagnosis - 5.What biochemical markers will help you?6. What imaging investigations you will suggest?7.What is your management strategy for this situation?

Q 1 List four significant findings in the image. a) Multiple round opacities in both lung fieldsb) Opacities are different in sizesc) They are peripherally placedd) Cardiac and hilar shadows appears normale) No pleural effusion

Q2 What is your radiological diagnosis ?Multiple pulmonary secondary metastatic tumours

Q 3 What organs / systems would you focus on during clinical evaluation of the patient? Thyroid, GI: colon and rectum, Pancreas, Kidneys, Prostate, TestiS, Bone

Q 4 In absence of obvious clinical clue to have a diagnosis - (a) What biochemical markers will help you?Tumour Markers: PSA, CEA, βHCG, α Fetoprotein (b) What imaging investigations you will suggest?

(i) USG of Abdomen / Scrotum (ii) USG of Thyroid

(iii) CT scan of Abdomen. Q 5 What is your management strategy for this situation?

a) Diagnosis of the primary lesionb) Treatment of primary disease and systemic treatment (Chemo/Hormone therapy)

for pulmonary conditions.c) Palliative care

Example: X-ray Answer key

This is to test your ability for rational interpretation of laboratory data in the context of clinical situation

You need to Take your time reading the whole data

mindfully Read all the questions and the data

again Answer precisely

A 50Y old man has developed deep jaundice for about two months and having high grade fever and vomiting for a week. His liver was felt enlarged and mildly tender. The following investigators were carried out and the results have been made available for your interpretations.

CBC- Hb. 10 gm/dlTLC: 24,000/cmm Polymorph - 81%Lymphocyte - 14%Monocyte - 4%Eosinophil - 1%

 

Blood sugar (Random)- 7.1mg/dl Blood Urea 48 mg/dLSerum creatinin 2.8 mg/dLS.Bilirubin- 16 mg/ dlS. AST - 104 unit/ lS. Alkaline phosphatase- 798 unit /lS. Amylase: 50 unit/L Serum Electrolytes Na 125 mEq / dL K 5.3 mEq / dL Cl 94mEq/dL HCO3 23 mEq/dL Prothrombin time - 29 secondsINR: 2.3HBSAg (screening)- PositiveCA 19-9: 69 U/ml

Questions: 1. What is your interpretation of the patient’s data?2. Write your initial management plan.

After a week of initial management patient had some clinical improvement. Following are the results of review investigations. Give your interpretation.

 CBC- Hb. 10 gm/dlTLC: 11,000/cmm Polymorph - 75%Lymphocyte - 14%Monocyte - 9%Eosinophil - 2%Blood sugar (Random)- 7.3mg/dl Blood Urea 35 mg/dLSerum creatinin 2.1 mg/dLS.Bilirubin- 9 mg/ dlS. AST - 94 unit/ l    

S. Alkaline phosphatase- 478 unit /lS. Amylase: 40 unit/L Serum Electrolytes Na 128 mEq / dL K 4.3 mEq / dL Cl 94mEq/dL HCO3 23 mEq/dL Prothrombin time - 21 secondsINR: 2.1HBSAg (Confirmatory)- Positive

Questions:3. Write your interpretation of the review data.4. Name further investigations you would suggest.

Answer key: 1. Patient is having the following conditions

1. Obstructive jaundice possibly due to carcinoma of pancreo-biliary origin indicated by raised CA 19-9.

2. Cholengitis indicated by polymorphonuclear leucocytosis3. Renal impairment and electrolyte imbalance4. Possible hepatitis-B virus carrier

2. Initial management1. Correction of dehydration and electrolyte imbalance 2. Broad spectrums antibiotic3. Vitamin-K parenteral

3. Improved blood count and LFT indicating control of cholengitis. Improvement of renal function with electrolyte imbalance correction.

4. Investigations1. Upper GI endoscopy - to inspect the duodenal papilla 2. MRCP- Non-invasive localisation of biliary obstruction, pancreatic mass

detection3. CT & guided FNAC -to detect and diagnose the pancreatic ca.4. ERCP- Diagnosis of peri-ampullary carcinoma, localisation of biliary

obstruction, setting to relieve biliary obstruction.

This is to test your counseling skills in surgical practice

Counseling takes a vital role in surgical managements

You need to Read the scenario and tasks several times Organize the core issues in your mind Write down the points you want to convey Have natural voice, maintain etiquette all along Use a single language, avoid medical terms

Scenario A 35year old lady, a college teacher and

mother of one child, presented with a small lump in her right breast in upper and outer quadrant . It measured 2cm in diameter, appeared mobile, brought no change in nipple and there were no palpable nodes in axilla. FNAC of the lump reported ‘duct cell carcinoma’. You, being the treating surgeon, have to convey the information to the patient in your hospital chamber in order to involve her in the treatment planning.

Tasks for Examinee:1. Create an easy atmosphere understanding the mental state of the

patient.2. Inform her about the findings and explain in an understandable

language the significance of these findings.3. Mention your provisional plan that you consider most appropriate, 4. Inform her about the alternate options and briefly discuss those. 5. Answer her queries in order to clarify her confusions.

Instructions to Examinee:1. Presume that you are working in a medical college hospital.2. A well informed person would play the role of the patient 3. You can use any language convenient to the patient 4. Station observer would assess your performance in verbal

communication skills using a structured check-list5. You may make notes on the paper provided in this station 

Verbal communication- CounselingExample page-2

Check list1. Welcomes her, ask her to take seat, asks how she was doing, says some

comforting words before serious talks2. Explains the reasons of this conversation3. States the nature of the disease in easy language4. Explains the evidences supporting the diagnosis 5. Narrates the provisional plan of treatment best for he given the circumstances 6. Takes questions and allows her to express her desires

1. Are you going to remove whole breast or part of it?2. I do not want to remove my breast. Is it possible?3. If the whole breast is not removed, would it cause any harm?4. Chemotherapy and radiotherapy cause much problem, can I avoid those?5. What are my chances of cure with the treatment you have suggested ?6. What are the chances growing the tumour again once removed?

7. Informs her of the alternate options of treatment with evidence based outcome8. Assures her about the overall surgical outcomes9. Informs her about the adjuvant treatments and accompanying hazards10.Concludes conversation giving her time to think about the whole issues and give

response at the earliest

Verbal communication- CounselingExample page-3

Verbal communication: Interactive

This is to test your interactive ability in professional conversations

It occurs between the examinee and a senior surgeon (interviewer) based on a scenario and set questions, but supplementary comes up as conversation goes on

You need to Listen to the question very carefully: catch the reason Answer precisely, never say everything Give a chance to ask the next question that you know Never say anything but evidence based information Skip quickly if something is not known to you

ScenarioA one year old girl was brought to the hospital by parents as she had facial defect since birth. Instruction to InterviewerAsk following questions to the examinee with regard to the management of patient’s cleft lip and palate. You are allowed to ask supplementary clarifying questions in response to the answers as and when required. 1.What is the diagnosis?2. What is the developmental basis of this abnormality?3. What are the present problems of this baby?4.What would be your advice to the parents regarding feeding and airway?5.What complications will arise if reconstruction is not done?6.What would be your management plan?7.What is the rationale behind the two stage operation?8.What further managements are required following reconstruction ?

Verbal communication: InteractiveExample page-1

Answer KeyWhat is the diagnosis?Unilateral complete Cleft lip, alveolus and palate ( left) What is the developmental basis of this abnormality?Failure of the fusion of the fronto-nasal and maxillary processWhat are the present problems of this baby?Cosmetic, suckling difficulty and nasal regurgitation, impaired speech development.What would be your advice to the parents regarding feeding and airway?Using Soft bottle, modified tits, enlargement of hole of tit, feeding plate and for airway- nursing in prone position(Ref. Bailey & love p-661)What complications will arise if untreated?Facial asymmetry, psycho-social developmental disorder, speech developmental disorder What would be your surgical plan?Reconstruction of lip and soft palate at the age of5-6 months and hard palate and gum pad 15-18 months (Ref. Bailey & love p-661)What is the rationale behind the two stage operation?Two stage closures encourages the physiological narrowing of the hard palate cleft to minimize surgical dissectionWhat further managements are required following surgeries?Hearing and speech therapy, dental care and facial revision surgeries

Verbal communication: Interactive Example page-2

This is to test your ability to write surgical documents as surgeons need to write documents in order to communicate with the people

You need to Read the scenario and the task very carefully Take your time in planning an outline: header>

body: each paragraph for an issue>footer Never miss a component ( Example: your

address, Tel,)

TaskThis is a written communication skills station. You are to write a “Death summary” of a patient who has expired 3 -4 hours back, presuming that, it is an important document for ‘Death Review Committee’ of the hospital. Instructions:You shall have to complete the report within 200 words. You will find in patient’s file, chronologically, bridged notes of patient history and physical examination, investigation, treatment, follow up and death confirmation.Please write your code number as you start writing your report Time limit: 10 Minutes

Written communication Example Page-1

Check listIncorporates the following in the death summary1. Patient particulars, admission time and date2. Admission presentation: Provisional diagnosis and

overall condition3. Immediate treatment on admission4. Diagnostic workup5. Diagnosis6. Intervention: Brief description with time and date7. Ongoing monitoring and progress of the disease8. Consultations and specialty opinions 9. Situation before death(deterioration sequence)10.Time and date of death11.Cause leading to death

Written communication Example Page-2

This is for testing your surgical skills that are essentially the standard or recommended techniques you follow while performing a surgical procedure

You need to Read the scenario and the tasks several times Go by the written instructions at the station Stick to standards of surgical skills, not you

style Go slow, but steady; ask for assistance

ProcedureYou will have to perform a basic surgical procedure on a stitching board using available instruments and materials. 

Task:1. Close the incision made on the board by a ‘continuous

interlocking’ suture considering it as planned skin incision2. Put surgeons’ knot at the beginning3. Put Aberdeen knot at the end Instructions:1. Introduce yourself with your Code number2. You don’t need to put on gloves3. Use 2/0 silk on curved cutting needle4. Ask for assistance

Allotted time: 5 minutes

Surgical skills Example page-1

Check listStarting knot1. Passes the needle at the end of the incision2. Makes first throw with double twist 3. Makes second throw with single twist to make a reef/squire knot Continuation of suture1. Enters the needle into the skin vertically- passes the needle along its long axis- exits at an

identical point on opposite side2. Keeps distance of entry/exit points from incision margins equal to its depth 3. Suture interlocks on side of the first knot4. Keeps distance between the stitches equal and half that of depth of the incision wound5. Maintains adequate tension approximating the wound marginEnd knot-Aberdeen 1. Stops the continuous suture at the other end by the final pass close to the just previous one

and forms a loop without tightening2. Passes several Aberdeen knots and adequately tightens by bedding those down3. Makes final pass of thread through loop to end the knot and cuts itGeneral considerations1. Holds needle at the tip of needle holder 2/3 away from tip2. Holds the wound margin with tooth dissecting forceps or skin hook while passing the needle3. Holds the needle holder and forceps properly4. Never touches the needle by hand

Surgeons need to become skillful in a number of areas in their practice

OSPE represents surgical practiceStations are constructed from our

daily experiencesMindful observation during training

period ensures a best preparation

Any question?