Part A is a written paper using multiple choice questions (MCQs) and Part B is an objective structured clinical examination (OSCE).
The Part A examination uses single best answer MCQs designed to test knowledge of both applied basic science and principles of surgery in general to a level that a surgical trainee should have achieved two to three years after qualification.
The Part B OSCE tests:
Anatomy and surgical pathology
Applied surgical science and critical care
Clinical and procedural skills
Topics within the syllabus modules may be examined in either Part A or Part B or both parts of the examination.
Module 1 Basic sciences
Objective To acquire and demonstrate sufficient knowledge of the basic scientific principles within the six categories listed below to understand, investigate and manage the common surgical conditions specified in module 2:
1 applied surgical anatomy
2 applied surgical physiology
3 applied surgical pathology (principles underlying system-specific pathology)
4 pharmacology (centred around the safe prescribing of common drugs) as applied to surgical practice
5 microbiology as applied to surgical practice
6 imaging (principles, advantages and disadvantages of various diagnostic and interventional imaging methods) Knowledge 1. Applied Surgical Anatomy Regional anatomy of thorax, abdomen, pelvis, perineum, limbs, spine, head and neck. Microscopic anatomy of tissues and organs of surgical relevance. Surgically related embryology and development. Surface anatomy. Imaging anatomy. 2. Applied Surgical Physiology General physiological principles including: o homeostasis o thermoregulation o metabolic pathways and abnormalities o blood loss and hypovolaemic shock o sepsis and septic shock o fluid balance and fluid replacement therapy o acid–base balance o bleeding and coagulation o nutrition. The physiology of specific organ systems relevant to surgical practice including the cardiovascular, respiratory, gastrointestinal, urinary, endocrine and neurological systems. 3. Applied Surgical Pathology General pathological principles including: o inflammation o wound healing o cellular injury o tissue death including necrosis and apoptosis o vascular disorders o disorders of growth, differentiation and morphogenesis. Surgical immunology. Surgical haematology. Surgical clinical chemistry. Principles of neoplasia and oncology including: o classification of tumours o tumour development and growth including metastasis o staging and grading of cancers Page 8 o cancer therapy including surgery, radiotherapy, chemotherapy, immunotherapy and hormone therapy o cancer registration o cancer screening. The pathology of specific organ systems relevant to surgical care including the cardiovascular, respiratory, gastrointestinal, genitourinary, central and peripheral neurological, skin, lymphoreticular and musculoskeletal systems; and pathology of the breast, endocrine and exocrine glands. 4. Pharmacology as applied to surgical practice The pharmacology and safe prescribing of drugs used in the treatment of surgical diseases including analgesics, antibiotics, cardiovascular drugs, antiepileptics, anticoagulants, respiratory drugs, renal drugs, drugs used for the management of endocrine disorders (including diabetes) and local and general anaesthetics. 5. Microbiology as applied to surgical practice Surgically important micro-organisms including bloodborne viruses. Soft tissue infections including cellulitis, abscesses, necrotising fasciitis, gangrene. Sources of infection. Sepsis and septic shock. Asepsis and antisepsis. Principles of disinfection and sterilisation. Antibiotics including prophylaxis and resistance. Principles of high-risk patient management. Hospital-acquired infections. 6. Imaging Core knowledge of diagnostic imaging and interventional techniques to include basic interpretation of X-rays, ultrasound, CT, MRI, PET and radionuclide scanning.
Module 2 Common congenital and acquired surgical conditions
Objective To demonstrate understanding of the relevant basic scientific principles (described in Module 1) for each of these surgical conditions and to be able to provide the relevant clinical care as defined in Modules 4 and 5. This module lists within nine topics the common surgical conditions, affecting both adults and children, for which trainees need to be able to demonstrate understanding of the relevant basic science specified in Module 1 in order to provide the clinical care described in Modules 4 and 5. These topics are: gastrointestinal disease; breast disease; vascular disease; cardiovascular and pulmonary disease; genitourinary disease; trauma and orthopaedics; diseases of the skin, head and neck; neurology and neurosurgery; and endocrine disease. Gastrointestinal disease Presenting symptoms or signs Dysphagia Vomiting Abdominal pain Dyspepsia Abdominal mass Abdominal distension Change in bowel habit Intestinal obstruction Page 9 Gastrointestinal haemorrhage Rectal bleeding Jaundice To include the following conditions Common congenital anomalies Benign and malignant disease of oesophagus, stomach, small and large bowel and appendix Perianal and rectal disease Benign and malignant disease of the liver, gall bladder, pancreas and spleen Abdominal wall hernia and stomas Acute abdominal emergencies, including adhesions, peritonitis and perforation of a viscus. Acute presentation of gynaecological pathology Breast disease Presenting symptoms or signs Pain and tenderness Breast lump Nipple discharge Gynaecomastia To include the following conditions Benign and malignant breast disease Mastitis and breast abscess Vascular disease Presenting symptoms or signs Common congenital anomalies Intermittent claudication Ischaemic rest pain Gangrene and ischaemic ulceration Acute limb ischaemia (embolism, thrombosis) Leg ulceration Varicose veins Swollen leg Pulsatile abdominal mass Transient ischaemic attacks and stroke To include the following conditions Atherosclerotic arterial disease affecting the cerebral, mesenteric, renal and upper and lower limb arteries Embolic and thrombotic arterial occlusive disease Diseases of the veins and lymphatics Vascular and neuropathic consequences of diabetes Abdominal and peripheral arterial aneurysms Amputations and rehabilitation Cardiovascular and pulmonary disease Presenting symptoms or signs Breathlessness and leg swelling Chest pain Cough and haemoptysis Cardiac arrhythmias and murmurs To include the following conditions Common congenital anomalies Coronary heart disease Diseases of the heart valves Cardiac failure Page 10 Benign and malignant lung disease including: o obstructive airways disease o restrictive lung disease o acute and chronic respiratory infection o bronchial carcinoma Genitourinary disease in males and females Presenting symptoms or signs Loin pain Haematuria Lower urinary tract symptoms (painful micturition, frequency) Urinary retention Renal failure Scrotal swellings Testicular pain Penile pathology Acute gynaecological symptoms To include the following conditions Common congenital anomalies Genitourinary malignancy Urinary calculus disease Urinary tract infection Benign prostatic hyperplasia Obstructive uropathy and urine diversion Testicular tumours and benign scrotal swelling Penile ulcers and carcinoma Gynaecological conditions relevant to the general surgeon Trauma and orthopaedics Presenting symptoms or signs Traumatic limb and joint pain and deformity Chronic limb and joint pain and deformity Back pain To include the following conditions Common congenital anomalies Simple fractures and joint dislocations Fractures around the hip and ankle Degenerative and inflammatory joint disease Bone and joint infection Compartment syndrome Spinal nerve root entrapment and spinal cord compression Metastatic bone cancer Metabolic bone disease Common peripheral neuropathies and nerve injuries Amputations and rehabilitation Diseases of the skin, head and neck Presenting symptoms or signs Common congenital anomalies Skin lesions Palpable neck lumps Common neck swelling, including salivary glands Lesions of the oral cavity Upper airway obstruction Ear pain and hearing loss To include the following conditions Page 11 Benign and malignant lesions of the skin, head and neck, including mouth, tongue and ear Neurology and neurosurgery Presenting symptoms or signs Headache Facial pain Visual impairment Confusion and memory loss Coma To include the following conditions Common congenital anomalies Space-occupying lesions from bleeding and tumour Cranial and peripheral nerve palsies General features of cerebral abscess and meningitis Endocrine disease Presenting symptoms or signs Thyroid nodules and goitre Acute endocrine crises To include the following conditions Common congenital anomalies Thyroid and parathyroid disease Adrenal gland disease Diabetes Diseases of the Lymphoreticular system Presenting symptoms or signs Lymphadenopathy Hepatosplenomegaly To include the following conditions Benign and malignant tumours Immunosuppression
Module 3 Basic surgical skills Objectives
Understanding the principles of safe surgery Preparation of the surgeon and patient for surgery Safe administration of appropriate local anaesthetic agents Acquisition of basic surgical skills in instrument and tissue handling including: o incision of superficial tissues accurately with suitable instruments o closure of superficial tissues accurately o tying secure knots o safe use of surgical diathermy o haemostasis of superficial vessels o methods of retraction o use and selection of drains o handling tissues gently with appropriate instruments Biopsy techniques Appropriate use of assistants Understanding the formation and healing of surgical wounds Knowledge Page 12 Principles of safe surgery Preparations for surgery Hand washing, scrubbing and gowning Use of surgical checklists including WHO Administration of local anaesthesia Choice of anaesthetic agent Safe practice Surgical wounds Classification Principles of wound management Pathophysiology of wound healing Scars and contractures Incision of skin and subcutaneous tissue: o Langer’s lines o choice of instrument o safe practice Closure of skin and subcutaneous tissue: o options for closure o suture and needle choice o safe practice Knot tying: o range and choice of materials for suture and ligation o safe application of knots for surgical sutures and ligatures Haemostasis: o surgical techniques o principles of diathermy Tissue handling and retraction: o choice of instruments Use of drains: o indications o types o management/removal Biopsy techniques Principles of skin cover (skin grafts and flaps) Principles of safe anastomosis Technical skills and procedures Preparation of the surgeon for surgery Effective and safe hand washing, gloving and gowning Preparation of a patient for surgery Creation of a sterile field Antisepsis Draping Administration of local anaesthesia Accurate and safe administration of local anaesthetic agent Incision of skin and subcutaneous tissue Ability to use scalpel, diathermy and scissors Closure of skin and subcutaneous tissue Accurate and tension-free apposition of wound edges Knot tying Single handed Double handed Instrument Superficial Deep Page 13 Haemostasis Control of bleeding vessel (superficial) Diathermy Suture ligation Tie ligation Clip application Transfixion suture Tissue retraction Use of tissue forceps Placement of wound retractors Use of drains Insertion Fixation Removal Tissue handling Appropriate application of instruments and respect for tissues Biopsy techniques Skill as assistant Anticipation of needs of surgeon when assisting
Module 4 The assessment of the surgical patient Objective
To demonstrate the relevant knowledge, skills and attitudes in assessing thesurgical patient. Clinical skills Surgical history and examination (elective and emergency) Constructing a differential diagnosis Planning and interpreting investigations Clinical decision making Team working and planning Case work-up and evaluation Taking consent for intermediate-level intervention, emergency and elective Interactive clinical communication skills: patients Interactive clinical communication skills: colleagues Principles of obtaining consent from vulnerable and non-competent adults
Module 5 Perioperative management Objectives
Preoperative assessment and management. Intraoperative care, including managing patient care in the perioperative period and conducting safe surgery in the operating theatre environment. Postoperative care including the assessment of common complications. Assessment and management of bleeding including the use of blood products. Coagulation, deep venous thrombosis and embolism. Use of antibiotics. Assessment and planning of perioperative nutritional management. Metabolic and endocrine disorders in relation to perioperative management. Knowledge and clinical skills Preoperative assessment and management Cardiorespiratory physiology Diabetes mellitus and other relevant endocrine disorders Fluid balance and homeostasis Renal failure Page 14 Pathophysiology of sepsis – prevention and prophylaxis Thromboprophylaxis Laboratory testing and imaging Risk factors for surgery and scoring systems Pre-medication and other preoperative prescribing Immunisation protocols for surgeons and patients Intraoperative care Safety in theatre including patient positioning and avoidance of nerve injuries Sharps safety Diathermy, laser use Infection risks Radiation use and risks Tourniquet use including indications, effects and complications Principles of local, regional and general anaesthesia Principles of invasive and non-invasive monitoring Methods of prevention of venous thrombosis Surgery in hepatitis and HIV carriers Fluid balance and homeostasis Temperature regulation Principles of cardiopulmonary bypass Perioperative care Principles of enhanced recovery following complex surgery to include basic protocols and potential clinical benefits Postoperative care Postoperative monitoring Cardiorespiratory physiology Fluid balance and homeostasis Diabetes mellitus and other relevant endocrine disorders Renal failure Ileus Pathophysiology of blood loss Pathophysiology of sepsis including SIRS and shock Multiorgan dysfunction syndrome Postoperative complications in general Methods of postoperative analgesia Nutritional management Methods of screening and assessment of nutritional status Perioperative nutrition Effects of malnutrition, both excess and depletion Metabolic response to injury Methods of enteral and parenteral nutrition Haemostasis and blood products Components of blood Mechanism of haemostasis including the clotting cascade Pathology of impaired haemostasis e.g. haemophilia, liver disease, massive haemorrhage Principles of administration of blood products Alternatives to use of blood products Patient safety with respect to blood products Coagulation, deep vein thrombosis and embolism Clotting mechanism (Virchow’s triad) Effect of surgery and trauma on coagulation Risk classification of DVT Tests for thrombophilia and other disorders of coagulation Page 15 Methods of prevention of DVT, mechanical and pharmacological Methods of investigation for suspected thromboembolic disease Role of CT pulmonary angiography, D-dimers and thrombolysis Principles of treatment of venous thrombosis and pulmonary embolism including anticoagulation Antibiotics Common pathogens in surgical patients Antibiotic sensitivities Antibiotic side-effects Principles of prophylaxis and treatment Metabolic and endocrine disorders in relation to perioperative management Pathophysiology of thyroid hormone excess and deficiency and associated risks from surgery Causes and effects of hypercalcaemia and hypocalcaemia Complications of corticosteroid therapy Causes and consequences of steroid insufficiency Complications of diabetes mellitus Causes and effects of hypernatraemia and hyponatraemia Causes and effects of hyperkalaemia and hypokalaemia Clinical skills Preoperative assessment and management History and examination of a patient Interpretation of preoperative investigations Management of comorbidity Resuscitation Appropriate preoperative prescribing Intraoperative care Safe conduct of surgery, including Correct patient positioning Avoidance of nerve injuries Management of sharps injuries Prevention of diathermy injury Prevention of venous thrombosis Postoperative care Assessment and monitoring of patient’s condition Postoperative analgesia Fluid and electrolyte management Detection of impending organ failure Initial management of organ failure Principles of and indications for dialysis Recognition, prevention and treatment of postoperative complications Thermoregulation Haemostasis and blood products Recognition of conditions likely to lead to bleeding diathesis Recognition of abnormal bleeding during surgery Appropriate use of blood products Management of the complications of blood product transfusion Coagulation, deep vein thrombosis and embolism Recognition of patients at risk Awareness and diagnosis of DVT and pulmonary embolism Role of duplex scanning, venography and D-dimer measurement Initiation and monitoring of treatment of venous thrombosis and pulmonary embolism Initiation of prophylaxis Page 16 Antibiotics Appropriate prescription of antibiotics Assessment and planning of preoperative nutritional management Arranging access to suitable artificial nutritional support, preferably via a nutrition team including dietary supplements, enteral nutrition and parenteral nutrition Metabolic and endocrine disorders History and examination in patients with endocrine and electrolyte disorders Investigation and management of thyrotoxicosis and hypothyroidism Investigation and management of hypercalcaemia and hypocalcaemia Investigation and management of hypernatraemia and hyponatraemia Investigation and management of hyperkalaemia and hypokalaemia Perioperative management of patients on steroid therapy Perioperative management of diabetic patients Technical skills and procedures Airway management Central and peripheral venous line insertion Chest drain insertion Urethral catheterisation
Module 6 Assessment and management of patients with trauma (including the multiply injured patient) Objectives
To assess and initiate management of patients: o with head and facial trauma o with a spinal cord injury o with chest trauma o with abdominal and urogenital trauma o with vascular trauma o with fractures or dislocations o with traumatic skin and soft tissue injury o with burns. To assess the multiply injured patient. To prioritise management in such situations as defined by Advanced Trauma Life Support, Advanced Paediatric Life Support etc. Knowledge General Scoring systems for assessment of the injured patient Major incident triage Differences in children Shock Pathogenesis of shock Shock and cardiovascular physiology Metabolic response to injury Adult respiratory distress syndrome Indications for using uncrossmatched blood Wounds and soft tissue injuries Gunshot and blast injuries Stab wounds Human and animal bites Nature and mechanism of soft tissue injury Principles of management of soft tissue injuries Principles of management of traumatic wounds Compartment syndrome Page 17 Burns Classification of burns Principles of management of burns Fractures and dislocations Classification Pathophysiology of fractures Principles of management Complications Joint injuries Organ-specific trauma Pathophysiology of thoracic trauma Pneumothorax Head injuries including traumatic intracranial haemorrhage,brain injury and maxillofacial injury Spinal cord injury Peripheral nerve injuries Blunt and penetrating abdominal trauma Hepatic and splenic trauma Vascular injury including iatrogenic injuries and intravascular drug abuse Crush injury Principles of management of skin loss including use of skin grafts and skin flaps Clinical skills General History and examination Investigation Referral to appropriate surgical subspecialties Resuscitation and early management of patient who has sustained thoracic, head, spinal, abdominal or limb injury according to Advanced Trauma Life Support, Advanced Paediatric Life Support guidelines Resuscitation and early management of the polytrauma patient Specific problems Management of the unconscious patient Initial management of skin loss Initial management of burns Prevention and early management of the compartment syndrome Management of hypothermia Technical skills and procedures Surgical airway management Central and peripheral venous line insertion Chest drain insertion Urethral catheterisation
Module 7 Surgical care of children Objectives
To assess and manage children with surgical problems, and understand the adult consequences of paediatric surgical history. Knowledge Assessment and management of common surgical conditions affecting children Physiological and metabolic response to injury and surgery Fluid and electrolyte balance Thermoregulation Safe prescribing Page 18 Obtaining consent To understand the issues of child protection and to take action as appropriate.
Module 8 Management of the dying patient Objectives and Knowledge
To be able to manage the dying patient appropriately in consultation with the palliative care team. To understand consent and ethical issues in patients certified DNAR (do not attempt resuscitation). To be able to communicate with the terminally-ill patient and their relatives appropriately and with empathy.
Module 9 Organ and tissue transplantation Objective
To understand the principles of organ and tissue transplantation. Knowledge Basic knowledge of transplant immunology including tissue typing, and, rejection Principles of immunosuppression Tissue donation and procurement Indications for organ transplantation Clinical Skills Principles of organ donation Circumstances in which consideration of organ donation is appropriate Principles of brain death Assessment of brainstem death Certification of death
Module 10 Professional behaviour and leadership skills Objectives
To provide good clinical care. To be a good communicator. To teach and to train. To keep up to date and know how to analyse data. To understand and manage people and resources within the health environment. To promote good health. To understand the ethical and legal obligations of a surgeon. The relevant knowledge and skills appropriate for core surgical traini