Mission

To train and produce General Surgeons who are competent and ready service in our Nation’s defense in both war and peace.

Vision

In the combat environment, the surgeon’s decision-making is rapidly saturated. Devastating injuries, limited supplies and blood, multiple patients, different evacuation systems and capabilities, ongoing engagements all need to be accounted for. Thus, it is not the technical ability to cannulate an artery, pack a bleeding liver, or repair an injured vessel that defines a military surgeon. Physician-soldiers must master the multidimensional chaos of combat trauma.

That is why we train.

Aims

We strive to:

• Prepare graduates for a career in academics, community practice, or additional fellowship training.
• Develop Surgeons utilizing a comprehensive training program focusing on graduated responsibility in both technical and decision-making skills.
• Prepare Surgeons who are ready to deploy, not only as Surgeons, but as medical leaders in service to our combat mission.
• Develop leaders who are capable of bringing groups together to accomplish the mission, whether it is a hospital-based clinical team, a research team, or an austere medical team.
• Utilize cutting-edge technology and simulation to facilitate expeditious technical learning in the modern surgical environment that necessitates fluency of skills in robotic surgery, laparoscopic surgery, and open surgery.
• Promote autonomy and continuous self-improvement in a supportive environment that helps each Surgeon become the best version of themselves.

Daily

1. Dedicated Intern and Medical Student lecture series
2. Morning report (discuss previous 24-hour events, cases, and consultations)

Weekly

1. Morbidity and Mortality Conference
2. Pre-operative academic conference (discuss selected upcoming cases)
3. Multi-disciplinary Tumor conference
4. Lecture from the SCORE curriculum
5. Physical activity (usually soccer)

Monthly

1. Staff lecture series
2. Trauma conference
3. Simulation exercise

Quarterly

1. Journal Club
2. Professional Development
3. Grand Rounds
4. Tissue Training
5. Cadaver Lab

Competency-based assessment methods

The residency program utilizes several methods by which the staff provides feedback and assessments of the six ACGME core competencies to the residents. Each of the following avenues for assessment incorporates the six ACGME core competencies.

• Junior residents are evaluated several times a month on their ability to succinctly present a patient at the program’s daily morning report.
• Each resident is evaluated by multiple attendings during every rotation of their residency on a quarterly basis via a web-based platform.
• The Residency Program’s clinical competency committee meets semi-annually to discuss each resident in depth. At this meeting the trainees are assessed based on sixteen milestones established by the ACGME.
• Senior residents (R3-R5) participate in biannual virtual mock oral examinations. This examination assesses the residents’ medical knowledge, professionalism, and interpersonal/communication skills. It is administered jointly by two residency programs (Madigan and Oregon Health Sciences University) and approximately two dozen staff.
• Faculty and staff evaluate and provide feedback on a daily basis through informal interactions in the clinic, operating room, and on the wards.

R4 residents are allowed a 1-month elective rotation in a specialty of their choice at Tacoma General Hospital (options are colorectal surgery, thoracic surgery, Minimally Invasive Surgery, Trauma and Acute Care Surgery, and Vascular Surgery).

• Day-time: Clinic team is on call for acute consults.
• Night-time: In-house Night Float Intern, In-house Night Float Junior (R2, R3), 15-minute recall Chief.

• Our residency program is located at a DOD Level 2 trauma center that is intimately involved in delivering excellent care to civilian and military trauma patients in our region. Our Surgery Residents work with fellow military Residents and co-manage trauma patients with our Emergency Medicine colleagues in a way that replicates the Surgery-Emergency Medicine relationship in the deployed setting.
• Our faculty are committed to operational surgery, and all have deployed overseas in support of our Nation’s missions. These unique experiences are highlighted in Academic conferences, particularly as they pertain to surgical and triage decision-making in the austere environment.
• Our dedicated research year is highly focused on the cutting edge of military-specific resuscitative surgery.
• All graduates participate in a weeklong, hands-on “CAPSTONE” course in austere military medicine/surgery.
• Our Residents have the opportunity to work with Special Operations medics on Live Tissue and Prolonged Field Care lanes.
• We offer Basic Endovascular Skills in Trauma (BEST) and Advanced Surgical Skills for Exposure in Trauma (ASSET) to our Residents multiple times a year.

Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) are required by the American Board of Surgery, and are therefore incorporated into our Residency.

Simulation Center

Madigan has a state-of-the-art Simulation Center, which includes simulation opportunities at the in-hospital “Just-in-Time” lab and the nearby multimillion dollar advanced simulation lab. The Just-in-Time center has all equipment necessary for practicing basic suturing, Fundamentals of Laparoscopic Surgery, Fundamentals of Endoscopic Surgery, laparoscopic digital simulation, and robotic simulation. Additionally, our dual-console DaVinci robots in the operating room have a user-friendly simulation “backpack” that allows Residents and staff alike to practice Robotic skills on the actual consoles. These opportunities are available to Residents 24 hours a day, seven days a week. In addition, we have proctored simulation sessions with either Chief Residents or Attendings once a month.

Cadaver Lab

Madigan General Surgery purchase an embalmed cadaver for educational purposes each year. We do 4-6 “Cadaver Labs” a year where we focus on steps of major abdominal, thoracic, vascular, and head and neck procedures, as well as the relevant anatomy.

Other

Madigan offers Basic Endovascular Skills in Trauma (BEST) and Advanced Surgical Skills for Exposure in Trauma (ASSET) to our Residents multiple times a year. These skills are critical in the deployed environment, where the General Surgeon is frequently asked to control bleeding vessels.

Madigan General Surgery uses a quarterly Leadership and Professional Development curriculum that is unique to medicine and based off episodes of the TV series “Scrubs.” This curriculum was developed by the Madigan Emergency Medicine Department and has been published in a major journal.

Our program has a dedicated research year in which they take over a well-established trauma swine model focused on studying and validating cutting-edge surgical resuscitation strategies for both military and civilian purposes. This study-line has resulted in hundreds of publications, more than a dozen grants, and numerous “Best Resident” awards at National and Regional conferences. Residents are also free to pursue both clinical and basic science research of their choosing, and they are well-supported by our staff and the Department of Clinical Investigations.

All residents participate in the institution’s longitudinal patient safety and QI curriculum which includes workshops, patient safety reporting, root cause analysis training, and other key patient safety topics as outlined in the GME Institutional Handbook. This training occurs as part of the PGY-1 orientation, intern to resident seminar, pre-senior resident seminar, and graduate capstone course.

At the program level, all General Surgery residents are required to participate in weekly M&M meetings. Additionally, all General Surgery residents are required to attend the Team STEPPS annual training. Faculty and senior residents are required to participate in Team STEPPS while in the OR with key individuals on the surgical team.

Residents are integrated and actively participate in interdisciplinary clinical QI and patient safety programs on twice monthly basis which covers the Institute of Healthcare Improvement curriculum. In addition, residents participate in membership in hospital level committees, to include Resident Council, Risk Management, Ethics, and Antimicrobial Stewardship Board committees. Assigned residents from the program are freed from clinical duties to attend these regularly scheduled meetings.

Ongoing Resident-driven QI projects are as follows:

1. Trauma bay efficiency project: This project involves complete restructure of the Madigan Trauma Bay. Residents have been working hand-in-hand with trauma surgeons, Emergency Medicine Leadership, CMS, and our Trauma Program Manager to modify surgical sets and maximize the efficiency of the care of trauma patients at Madigan.
2. Protocol standardization project: This project seeks to standardize admission protocols for trauma and acute care patients. Specific protocols include alcohol withdrawal, gastrograffin challenge, spine trauma, intracranial hemorrhage, rib fracture, chest tube management, and DVT prophylaxis. This is an ambitious project requiring input and buy-in from our EMR system experts as well as trauma and acute care surgery leadership.
3. Surgical Care Communication: A structured tool to aid communication between our teams and ICU medical and ICU nursing teams to address common friction points and facilitate co-management of Surgery primary patients in the ICU while still meeting Leapfrog ICU metrics.
4. Simethicone in Foregut Surgery: This project looks at routine simethicone use in foregut and bariatric surgery to see if it improves subjective patient experience and objective pain scores and medication use.
5. Improved EMR access in the OR: This project required multidisciplinary input and the support of hospital leadership, Department of Anesthesia leadership, and Technical Support leadership. The end result has been significantly improved access to the EMR in the operating room by adding computer systems, and more importantly, adding “Tap n’ Go” access to those systems.

Madigan General Surgery uses a quarterly Leadership and Professional Development curriculum that is unique to medicine and based off episodes of the TV series “Scrubs.” This curriculum was developed by the Madigan Emergency Medicine Department and has been published in a major journal.

Madigan Army Medical Center (Tacoma, Washington)

• All Years: General Surgery, Thoracic Surgery, Pediatric Surgery, Plastic Surgery, Acute Care Surgery, Trauma Surgery, Vascular Surgery, Hepatobiliary Surgery, Neurosurgery
• R2 and 4: GI - Endoscopy

Multi-care/Tacoma General Hospital (Tacoma, Washington)

• R1: Trauma Critical Care
• R2: Trauma and Acute Care Surgery, Bariatric Surgery, Colorectal Surgery, Hepatobiliary Surgery
• R3: Trauma and Acute Care Surgery, Vascular Surgery, Bariatric Surgery, Colorectal Surgery, Hepatobiliary Surgery
• R4: Bariatric Surgery, Colorectal Surgery, Hepatobiliary Surgery
• R5: Vascular Surgery

Harborview Medical Center (Seattle, Washington)

• R1: Burn Critical Care
• R2: Trauma Critical Care
• R3: Trauma and Acute Care Surgery
• R4: Trauma Chief

University of Washington Medical Center (Seattle, Washington)

• R2: Cardiothoracic Critical Care

Mary Bridge Children’s Hospital (Tacoma, Washington)

• R2 and R3: Pediatric Surgery

Sacred Heart Medical Center (Spokane, Washington)

• R4: Head and Neck Surgery, General Surgery

4th year Medical Students are invited to rotate on the Madigan General Surgery service. These rotations are highly structured educational opportunities that follow the classic Oslerian model of bedside teaching rounds. Medical Student teams are led by a Chief Resident, and also include PGY-1 residents and Junior Residents. Medical Students receive a small-group daily lecture led by a staff member. Each week consists of two clinic days, two Operating Room days, and a dedicated Academic Day (as described above). Academics rely heavily on Socratic teaching methodology, so studying ahead is key to performance.

Medical students are advised to schedule interviews with faculty during the last week of their rotations. These are face-to-face interviews. A minimum number of interviews is not set, however students are advised to meet with the Program Director, Associate Program Directors, and other faculty of their choosing. Ultimate ranking of students is based off feedback from interviews, performance in academics and daily rounds, and their ability to function in a team.

Program graduates take the written American Board of Surgery (ABS) Qualifying Exam (QE). This exam is offered annually. Those who pass the QE become eligible to take the oral American Board of Surgery Certifying Exam (CE), which is offered four times a year. To become fully board certified, applicants are eligible to take board certification exam immediately upon graduation. To be eligible to take specialty board exams, graduates must complete all pre-requisites required by the American Board of Surgery before applying for the QE (see Get Certified | Initial Certification - American Board of Surgery (absurgery.org).

Prerequisites:

1. Medical School: Surgeons seeking board certification by the ABS must have graduated from an accredited medical school in the U.S. or Canada or be certified by the Educational Commission for Foreign Medical Graduates.
2. Residency and Fellowship Training: Following medical school, surgeons must complete at least five years of training in a residency program approved by the Accreditation Council for Graduate Medical Education or the Royal College of Physicians and Surgeons of Canada. Certification in one of several ABS subspecialties then requires an additional 1-2 years of fellowship training.
3. Experience: During their training, surgeons must acquire extensive operative experience and a broad knowledge of disease management. Resident Case logs must reflect minimum case numbers over a broad spectrum of diseases and procedures.
4. Application: Upon completion of their surgical training, surgeons can apply to enter the ABS initial certification process. When applying, they must fully document their training and operative experience, and the director of their training program must attest to their surgical skills, ethics and professionalism.
5. Approval: If their application is approved, the surgeon is admitted to the required ABS exams for certification.
6. Medical License: In addition, all surgeons must hold a valid, full and unrestricted U.S. or Canadian medical license before they can become certified.
7. Written Exam: Surgeons must first pass a lengthy written examination known as the Qualifying Examination, which assesses their surgical knowledge.
8. Oral Exam: Surgeons must then pass an oral examination called the Certifying Examination, which tests their surgical judgment and decision making. Candidates are examined by experienced surgeons who evaluate their ability to diagnose and treat diverse surgical problems.
9. Certification: If successful on both examinations, the surgeon is deemed board certified and becomes a diplomate of the ABS.

Residents have the opportunity to become formal instructors of Advanced Trauma Life Support (ATLS) and Stop the Bleed. Senior Residents lead teaching rounds and guided discussions in pre-operative conference.

Our residents participate in Grand Rounds presentations, Morbidity & Mortality (M&M) presentations, as well as in Multidisciplinary Tumor Board.

• Trauma and Acute Care Surgery
• Colorectal Surgery
• Surgical Oncology
• Minimally Invasive Surgery
• Pediatric Surgery
• Plastic Surgery
• Neurosurgery
• Vascular Surgery

PGY-1 residents are assigned mentors prior to starting Residency. These mentors have volunteered and are selected for the incoming PGY-1 residents based on common interests and personality matches (elicited from the mentors and the PGY-1 residents). After the PGY1 residency year, PGY-2 residents may select any of the faculty as their mentor but must maintain a mentor throughout residency training. Residents and mentors are to meet at least quarterly to discuss feedback, career goals, or any concerns the resident may have. Mentors are always present for the semiannual “Milestones” evaluation, as they are in a unique position to be a resident advocate if performance concerns are raised.

Wellness Activities include the following:

Annual Resident Retreat

Two full clinical days off work for the entire Resident compliment to bond (location determined by Chief Residents). The retreat allows the residents to provide unvarnished feedback without the presence of attendings. These resident-led sensing sessions allow them to have a voice and provide actionable feedback for constantly improving the program.

Weekly Sports

Physical fitness and overall health are emphasized in a weekly sports activity that occurs at the conclusion of the weekly “Academic Day.”

Resilience and Professionalism Curriculum

Published curriculum based on episodes of the television series “Scrubs.” It was developed and adopted by the Madigan Internal Medicine Department and has been well-received by General Surgery Residents.

Resident Free Days

Residents are offered approximately 5 “Resident Free Days” per year. On these days the Residents round on their patients and then sign-out to the on-call Attending Surgeon for the day. The day is planned by the Chief Resident class and is designed to be a team-building endeavor. Past examples are rock-climbing, skiing, snowshoeing, skeet shooting, bowling, etc.