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Guidelines for

Competency Based Training Programme

in

DNB- GENERAL SURGERY

 

 

 

NATIONAL BOARD OF EXAMINATIONS

Medical Enclave, Ansari Nagar, New Delhi-110029, INDIA

Email: mail@natboard.edu.in             Phone: 011 45593000

 

CONTENTS

 

  1. INTRODUCTION

 

  1. OBJECTIVES OF THE PROGRAMME

    1. Programme goal

    2. Programme objective

 

  1. ELIGIBILITY CRITERIA FOR ADMISSION

 

  1. TEACHING AND TRAINING ACTIVITIES

 

  1. SYLLABUS

 

  1. COMPETENCIES

 

  1. THESIS & THESIS PROTOCOL

 

  1. LOG BOOK

 

  1. NBE LEAVE GUIDELINES

 

  1. EXAMINATION –

 

  1. FORMATIVE ASSESSMENT

  2. FINAL THEORY & PRACTICAL

 

  1. RECOMMENDED TEXT BOOKS AND JOURNALS

 

INTRODUCTION

 

 

Preamble

 

 

After qualifying in the final examination of the NBE, the candidate should be able to function as a specialist in General Surgery. This requires a thorough knowledge of the fundamentals. He/She should be reasonably acquainted with the recent advances and be able to perform essential elective and emergency operative procedures independently. He/She should be able to make decisions regarding patient management and adopt favorable attitudes. During this period, the candidate will also acquire skills of experience in research methodology by writing a dissertation / thesis.

 

PROGRAMME GOAL

 

The goal of DNB course in Surgery is to produce a competent surgeon who:

 

 

  • Has acquired the competence pertaining to surgery that is required to be practised in the community and at all levels of health care system

  • Has acquired the skills to manage the patients of trauma and all life saving surgeries effectively.

  • Has acquired skill in effectively communicating with patient and his attendants.

  • Has the desired surgical skills to independently operate on elective and emergency cases

  • Is aware of the latest developments in the field of surgery

  • Is oriented to principles of research methodology

  • Has acquired skills in educating medical and paramedical professionals

 

 

PROGRAMME OBJECTIVES

 

Objectives

 

 

The aim of the courses is to develop human recourses and personnel in the field of surgery who shall:

  1. Provide the health care to the patients needing surgical care with  principles and ethics.

  2. Teach and train future undergraduates and postgraduates medical students and junior doctors in General Surgery in Hospitals and other Institutions.

  3. Carry out and guide research to improve the practice of the art  and science of surgery

  4. Have management capabilities to manage personnel and budgets to make health care more cost-effective

  5. Organize health teams to provide care during natural or man-made calamities.

 

  1. Develop further in the areas of their interest and/or specialize to practice existing or new specialties allied to surgery through further training programs as required

 

At the end of the course, the Diplomate of National Board in Surgery shall be  able to:

 

  1. Practice the art and science of surgery in his/her field of practice and seek and provide consultation as required. He/She will be able to provide comprehensive and good quality surgical care in general surgery including pre-operative and postoperative care

  2. Conduct research and communicate the findings, result and conclusion to his fraternity

  3. Acquire necessary skills of teaching and training his junior colleagues and medical students and Para-medical personnel

  4. Keep abreast with the latest developments by self learning and/or participating in continuing medical education programs

  5. Organize and manage administrative responsibilities in the routine day to day work as well as new situations including natural and/or man-made accidents/ calamities

  6. Manage situations calling for emergency interventions in the sphere of surgical specialties and also routine problems in their areas within the ambit of the general surgeon

  7. Exhibit awareness of the importance of surgical audit and the need for considering cost affectivity in patient management

  8. Be aware of one’s professional and infrastructural limitations and be able to refer to appropriate centers at the optimum time, when required

  9. Exhibit awareness of the need for accurate documentation in medical records including medico-legal cases.

  10. Adopt ethical procedures in the field of doctor-patient relationship

 

  1. Exhibit proper attitude in dealing with patients and relatives and be able to communicate with them effectively

  2. To develop the skill of innovation and improvisation in times of need.

 

ELIGIBILITY CRITERIA FOR ADMISSIONS TO THE PROGRAMME

 

(A)DNB General Surgery Course:

 

  1. Any medical graduate with MBBS qualification , who has qualified the Entrance Examination conducted by NBE and fulfill the eligibility criteria for admission to DNB Broad Specialty courses at various NBE accredited Medical Colleges/ institutions/Hospitals in India is eligible to participate in the Centralized counseling for allocation of DNB General Surgery seats purely on merit cum choice basis.

 

  1. Admission to 3 years post MBBS DNB General Surgery course is only through Entrance Examination conducted by NBE and Centralized Merit Based Counseling conducted by National Board of Examination as per prescribed guidelines.

 

Duration of Course : 3 Years

 

TEACHING AND TRAINING ACTIVITIES

 

 

The fundamental components of the teaching programme should include:

  1. Case presentations & discussion- once a week

  2. Seminar – Once a week

  3. Journal club- Once a week

  4. Grand round presentation (by rotation departments and subspecialties)- once a week

  5. Faculty lecture teaching- once a month

  6. Clinical Audit-Once a Month

  7. A poster and have one oral presentation at least once during their training period in a recognized conference.

 

The rounds should include bedside sessions, file rounds & documentation of case  history and examination, progress notes, round discussions, investigations and management plan) interesting and difficult case unit discussions.

 

The training program would focus on knowledge, skills and attitudes (behavior), all essential components of education. It is being divided into theoretical, clinical and practical in all aspects of the delivery of the rehabilitative care, including methodology of research and teaching.

 

Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary in view of an inadequate exposure to the subject in the undergraduate curriculum.

 

Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in a period of three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

 

Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing and management in rehabilitation practice.

 

Bedside: The trainee would work up cases, learn management of cases by discussion with faculty of the department.

 

Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation by other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

 

Research: The student would carry out the research project and write a thesis/ dissertation in accordance with NBE guidelines. He/ she would also be given exposure  to partake in the research projects going on in the departments to learn their planning, methodology    and    execution    so    as    to    learn    various    aspects    of  research.

 

SYLLABUS

 

 

The following pages comprise schedules of knowledge and operative  skills, which provide a syllabus for training in general surgery and its sub-specialties. The knowledge required includes the basic science relevant to each topic. There is no intention to limit knowledge and operative experience. Trainees, as part of their general surgical training, must acquire competence in the scheduled operations but will also have experience of other procedures from the sub- specialty departments.

 

Knowledge: The Postgraduates are required to acquire sound knowledge of the below listed topics. The list includes topics found in most standard surgical textbooks. The candidates should also be familiar with recent advances and current controversies.

 

  1. Applied Basic Sciences include applied anatomy, physiology, biochemistry, microbiology, pharmacology and pathology.

 

  1. General Surgical Topics include the following:

 

  • History of Surgery

  • Molecular and Cell Biology

  • Mediators of Inflammatory Response

  • Regenerative Medicine

  • Fluids and Electrolyte balance/ Acid – Base metabolism

  • Wound Healing and Wound Management

  • Pathophysiology and Management of Shock

  • Principles of Operative Surgery: Asepsis, Sterilization and Antiseptics

  • Surgical Infections and Antibiotics

  • Nutrition and Metabolism

  • Principles of Burn Management

  • Principles of Oncology

  • Principles of Laparoscopy, Endoscopy and Robotics

  • Hemostasis, Blood Transfusion

  • Trauma: Assessment of polytrauma, triage, basic and advanced trauma

  • Basic Principles of Anesthesia

  • Informed Consent and Medico legal Issues

 

  • Pediatric Surgery

  • Organ Transplantation

  • Molecular Biology and Genetics

  • Hernias: Types of hernias, repair techniques

  • Breast Diseases: Benign breast disorders, investigations, screening, genetics, Breast Cancer

  • Thyroid Disorders: Solitary nodule, investigations, multinodular goiter, Graves disease malignancies

  • GIT Diseases

  • Urogenital disease

  • Cardio thoracic disease

  • Hepatobilary disease

  • Surgery in CNS disorder

  • Diabetes and Renal failure in Surgery

  • HIV AIDS in Surgery (Universal Safety precautions)

 

3.Imaging modalities in Surgery

  • X-ray and Angiography

  • MRI,  Ultrasound, CT, PET, Etc.

  • Image guided interventional procedures

 

PRE-OPERATIVE MANAGEMENT

 

Pre-operative Management

 

  • Assessment of fitness for anesthesia and surgery.

  • Tests of respiratory, cardiac and renal function.

  • Management of associated medical conditions, e.g.: diabetes; respiratory disease, cardiovascular disease; malnutrition; anemia; steroid, anticoagulant, Immunosuppressant and other drug therapy.

  • Nutritional Management

 

Infection

 

  • Pathophysiology of the body’s response to infection.

  • The sources of surgical infection - prevention and control.

  • Surgically important micro-organisms.

  • Principles of asepsis and antisepsis.

  • Surgical sepsis and its prevention.

  • Aseptic techniques.

  • Skin preparation.

  • Antibiotic prophylaxis.

  • Sterilisation.

  • HIV

 

 

Investigative and Operative Procedures

 

  • Excision of cysts and benign tumours of skin and subcutaneous tissue.

  • Principles of techniques of biopsy.

  • Suture and ligature materials.

  • Drainage of superficial abscesses.

  • Basic principles of bowel anastomosis.

 

Anesthesia

 

  • Principles of anesthesia.

  • Pre-medication and sedation.

  • Local and regional anesthesia.

  • Care and monitoring of the anaesthetized patient.

 

Theatre Problems

 

  • Surgical technique and technology.

  • Diathermy - principles and precautions.

  • Lasers - principles and precautions.

  • Explosion hazards relating to general anesthesia and endoscopic Surgery.

  • Tourniquets - uses and precautions.

  • Prevention of nerve and other injuries in the anaesthetized patient.

  • Surgery in hepatitis and HIV carriers (special precautions).

  • Disorders of coagulation and haemostasis (prophylaxis of thromboembolic disease).

 

 

PRE-OPERATIVE MANAGEMENT

 

Skin and Wounds

 

  • Pathophysiology of wound healing.

  • Classification of surgical wounds.

  • Principles of wound healing.

  • Incisions and their closure.

  • Suture and ligature materials.

  • Scars and contracture.

  • Wound dehiscence.

  • Dressings.

 

Fluid Balance

 

  • Assessment and maintenance of fluid and electrolyte balance.

 

  • Techniques of venous access.

  • Nutritional support - indications, techniques, total parenteral nutrition.

 

Blood

 

  • Disorders of coagulation and haemostasis.

  • Blood    transfusion    -     indications,    hazards,     complications,    plasma substitutes.

  • Haemolytic disorders of surgical importance.

  • Haemorrhagic disorders; disorders of coagulation.

 

Post-operative Complications

 

  • Post-operative    complications    -    prevention,    monitoring,    recognition, management.

  • Ventilatory support - indications.

 

Post-operative Sequelae

 

  • Pain control

  • Immune response to trauma, infections and tissue transplantation.

  • Pathophysiology of the body’s response to trauma.

  • Surgery in the immuno-compromised patient.

 

TRAUMA

 

Initial Assessment and Resuscitation after Trauma

 

  • Clinical assessment of the injured patient.

  • Maintenance of airway and ventilation.

  • Hemorrhage and shock. BLS, ATLS

 

Chest, Abdomen and Pelvis

 

  • Cardio respiratory physiology as applied to trauma.

  • Penetrating chest injuries and pneumothorax.

  • Rib fractures and flail chest.

  • Abdominal and pelvic injuries.

 

 

Central Nervous System Trauma

 

  • Central nervous system: anatomy and physiology relevant to clinical examination of the central nervous system; understanding of its  functional

 

disorders particularly those caused by cranial or spinal trauma; and interpretation of special investigations.

  • Intracranial hemorrhage.

  • Head injuries, general principles of management.

  • Surgical aspects of meningitis.

  • Spinal cord injury and compression.

  • Paraplegia and quadriplegia - principles of management.

 

Special Problems

 

  • Pre-hospital care.

  • Triage.

  • Trauma scoring systems.

  • Traumatic wounds - principles of management.

  • Gunshot and blast wounds.

  • Skin loss - grafts and flaps.

  • Burns.

  • Facial and orbital injuries.

 

Principles of Limb Injury

 

  • Peripheral nervous system - anatomy and physiology.

  • Fractures - pathophysiology of fracture healing.

  • Non-union delayed union, complications.

  • Principles of bone grafting.

  • Traumatic edema, compartment and crush syndromes, fat embolism.

  • Brachial plexus injury.

 

INTENSIVE CARE

 

Cardiovascular

 

  • The surgical anatomy and applied physiology of the heart relevant to clinical cases.

  • Physiology and pharmacological control of cardiac output, blood flow, blood pressure, and coronary circulation.

  • Cardiac arrest, resuscitation.

  • Monitoring of cardiac function in the critically ill patient, central venous pressure, pulmonary wedge pressure, tamponade, cardiac O/P measurements.

  • The interpretation of special investigations.

  • The management of hemorrhage and shock.

  • Pulmonary edema.

  • Cardiopulmonary bypass - general principles, cardiac support.

 

Respiratory

 

  • The surgical anatomy of the airways, chest wall, diaphragm and thoracic viscera.

  • The mechanics and control of respiration.

  • The interpretation of special investigations; lung function tests, arterial blood gases, radiology.

  • The understanding of disorders of respiratory function caused by trauma, acute surgical illness and surgical intervention.

  • Respiratory failure.

  • Complications of thoracic operations.

  • Adult respiratory distress syndrome.

  • Endotracheal intubation, laryngotomy, tracheostomy.

  • Artificial ventilation.

 

Multisystem Failure

 

  • Multisystem failure.

  • Renal failure - diagnosis of renal failure, complications of renal failure.

  • GI tract and hepatic failure.

  • Nutrition.

 

Problems in Intensive Care

 

  • Sepsis, predisposing factors, organisms causing septicemia.

  • Complications of thoracic operations.

  • Localized sepsis, pneumonia, lung abscess, bronchiectasis, empyema, mediastinitis.

 

Principles of ICU

 

  • Indications for admission.

  • Organization and staffing.

  • Scoring.

  • Costs.

 

NEOPLASIA: TECHNIQUES AND OUTCOME OF SURGERY

 

Principles of Oncology

 

  • Epidemiology of common neoplasms and tumour-like conditions; role of cancer registries.

  • Clinico-pathological staging of cancer.

 

  • Pathology, clinical features, diagnosis and principles of management of common cancers in each of the surgical specialties.

  • Principles of cancer treatment by surgery, radiotherapy, chemotherapy, immunotherapy and hormone therapy.

  • The principles of carcinogenesis and the pathogenesis of cancer relevant to the clinical features, special investigations, staging and the principles of treatment of the common cancers.

  • Principles of molecular biology of cancer, carcinogenesis; genetic factors; mechanisms of metastasis.

  • Tumor Biology and Tumor Markers

 

Cancer Screening and Treatment

 

  • The surgical anatomy and applied physiology of the breast relevant to clinical examinations, the interpretation of special investigations, the understanding of disordered function and the principles of the surgical treatment of common disorders of the breast.

 

  • The breast: acute infections; benign breast disorders; nipple discharge; mastalgia, Carcinoma of breast; mammography; investigation and treatment.

  • Screening program

 

Techniques of Management

 

  • Terminal care of cancer patients; pain relief.

  • Rehabilitation.

  • Psychological effects of surgery and bereavement.

 

Ethics and the Law

 

  • Medical/legal ethics and medico-legal aspects of surgery.

  • Communication with patients, relatives and colleagues.

 

Outcome of Surgery

 

  • The evaluation of surgery and general topics.

  • Decision-making in surgery.

  • Clinical audit.

  • Statistics and computing in surgery.

  • Principles of research and design and analysis of clinical trials.

  • Critical evaluation of innovations - technical and pharmaceutical.

  • Health service management and economic aspects of surgical care.

 

LOCOMOTOR SYSTEM

 

Musculo-skeletal anatomy and physiology relevant to clinical examination of the locomotor system and to the understanding of disordered locomotor function, with emphasis on the effects of acute musculoskeletal trauma.

 

Effects of Trauma and Lower Limb

 

  • Effects of acute musculo-skeletal trauma.

  • Common fractures and joint injuries.

  • Degenerative   and   rheumatoid   arthritis   (including   principles   of   joint replacement).

  • Common disorders of the lower limb.

  • Amputations and prosthesis.

 

Infections and Upper Limb

 

  • Common soft tissue injuries and disorders.

  • Infections of bones and joints (including implants and prostheses).

  • Pain in the neck, shoulder and arm.

  • Common disorders of the hand, including hand injuries and infections.

 

Bone Disease and Spine

 

  • Common disorders of infancy and childhood.

  • Low back pain and sciatica.

  • Metabolic bone disease (osteoporosis, osteomalacia).

  • Surgical aspects of paralytic disorders and nerve injuries.

 

VASCULAR

 

The surgical anatomy and applied physiology of blood vessels relevant to clinical examination, the interpretation of special investigations and the understanding of the role of surgery in the management of cardiovascular disease

 

 

Arterial Diseases

 

  • Chronic obliterative arterial disease.

  • Amputations.

  • Aneurysms.

  • Carotid disease.

  • Special techniques used in the investigation of vascular disease.

 

  • Limb    ischaemia:    acute    and    chronic;    clinical   features;    gangrene; amputations for vascular disease.

  • Principles of reconstructive arterial surgery.

  • Atherosclerosis

  • Principles of Angioplasty/stenting

  • Thrombolysis

  • Reno-vascular disease

  • Raynaud’s/vasospastic disorders

  • Lymphoedema

  • Cerebrovascular disease

  • Vasculitis

  • Mesenteric ischaemia

  • Graft prosthetics

  • Graft surveillance

  • Autonomic dysfunction

  • Reperfusion injury

  • Ischaemic limb Arterial trauma

  • Hyper/hypo coagulable state

  • Arteriography

  • Continuous wave doppler

  • Duplex ultrasound

 

Venous Diseases

 

  • Vascular trauma and peripheral veins.

  • Varicose veins.

  • Venous hypertension, post-phlebitic leg, venous ulceration.

  • Disorders of the veins in the lower limb.

  • Deep venous thrombosis and its complications.

  • Chronic ulceration of the leg.

  • Thrombosis and embolism.

 

Lymphatics and Spleen

 

  • Thromboembolic disease.

  • Spleen; role of splenectomy; hypersplenism.

  • Lymph nodes; lymphoedema.

  • Surgical aspects of auto-immune disease.

  • The anatomy and physiology of the haemopoeitic and lymphoreticular systems.

  • Surgical aspects of disordered haemopoiesis.

 

HEAD, NECK and ENDOCRINE

 

The surgical anatomy and applied physiology of the head and neck relevant to clinical examination, the interpretation of special investigations, the  understanding of disorders of function, and the treatment of disease and injury involving the head and neck.

 

The Head

 

  • Laryngeal disease; maintenance of airway; tracheostomy.

  • Acute and chronic inflammatory disorders of the ear, nose, sinuses and throat.

  • Intracranial complications.

  • Foreign bodies in ear, nose and throat.

  • Epistaxis.

  • Salivary gland disease.

  • The eye - trauma, common infections.

 

Neck and Endocrine Glands

 

The surgical anatomy and applied physiology of the endocrine glands relevant to clinical examination, the interpretation of special investigations, the  understanding of disordered function and the principles of the surgical treatment of common disorders of the endocrine glands.

 

  • Common neck swellings.

  • Thyroid: role of surgery in diseases of the thyroid; complications of thyroidectomy; and the solitary thyroid nodule.

  • Parathyroid; hyperparathyroidism; hypercalcaemia.

  • Secondary hypertension.

  • Pituitary Gland

  • Adrenal cortex

  • Adrenal medulla

  • Gut as endocrine organ

  • Endocrine pancreas and the management of:-

  • Thyrotoxicosis

  • Adrenal insufficiency

  • Hyper/hypo thyroidism

  • Carcinoid syndrome

  • Counselling and screening in familial disease

  • Anaesthetic and pharma-cological problems

  • Radio-immuno assays

  • Imaging techniques

  • Histo/cyto pathology

 

Skin in Surgical Disorders

 

  • Skin and Subcutaneous Tissue / soft tissue

 

Paediatric Surgical Disorders

 

  • Neonatal physiology: the special problems of anaesthesia and surgery in the newborn; and the principles of neonatal fluid and electrolyte balance.

  • Correctable congenital abnormalities.

  • Common paediatric surgical disorders: cleft lip and palate; pyloric  stenosis; intussusception; hernia; maldescent of testis; torsion; and diseases of the foreskin.

  • RIF pain

  • Testicular pain

  • Paediatric trauma

  • Burns

  • Intussusception

  • Pyloric stenosis

  • Hirschprung’s disease

  • Ano-rectal anomalies

  • Tracheo-oesophageal fistula

  • Spina bifida

  • Congenital small bowel obstruction

  • Intestinal malrotation

  • Associated anomalies

  • Paediatric oncology

  • Management of less complex abdominal trauma

  • Hydrocephalus

 

ABDOMEN

 

The surgical anatomy of the abdomen and its viscera and the applied physiology of the alimentary system relevant to clinical examination, the interpretation of common special investigations, the understanding of disorders of function, and the treatment of abdominal disease and injury.

 

Abdominal Wall

 

  • Anatomy of the groin, groin and other ventral hernias, acute and elective; clinical features of hernias; complications of hernias.

  • Anterior abdominal wall, anatomy, incisions, laparoscopic access.

 

Acute Abdominal Conditions

 

  • Peritonitis; intra-abdominal abscesses.

  • Common acute abdominal emergencies.

  • Intestinal obstruction; paralytic ileus.

  • Intestinal fistulae.

  • Investigation of abdominal pain.

  • Investigation of abdominal masses.

  • Gynaecological causes of acute abdominal pain.

  • Pelvic inflammatory disease.

  • Assessment of the acute abdomen

  • Appendicitis and right iliac fossa pain

  • Peritonitis

  • Acute intestinal obstruction

  • Intestinal pseudo-obstruction

  • Biliary tract emergencies

  • Acute pancreatitis

  • Strangulated hernia

  • Intestinal ischaemia

  • Swallowed foreign bodies

  • Gastrointestinal bleeding

  • Toxic megacolon

  • Superficial sepsis and abscesses

  • Acute ano-rectal sepsis

  • Ruptured aortic aneurysm

  • Acute presentations of urological disease

  • Acute presentations of gynaecological disease

  • Sub-total colectomy

  • Diagnostic laparoscopy

  • Gastrectomy for bleeding

  • Endoscopy for upper GI obstruction

  • Laparotomy for perforated colon

  • Suture of bleeding peptic ulcer

  • Emergency cholecystectomy

  • Exploration of scrotum for torsion

  • Emergency hernia repair

  • Laparotomy for abdominal

  • Reduction of paraphimosis

  • Laparotomy for small bowel injury

  • Diagnostic peritoneal lavage

  • Intestinal obstruction

  • Splenic repair

  • Hartmann’s operation

  • Operation for ruptured liver

 

  • Pancreatic debridement

  • Median sternotomy

 

Reconstructive Surgery

 

  • Myocutaneous flaps

  • Tissue expanders

  • Breast reduction

 

Colorectal