INTERMEDIATE MODULE

IN
SURGERY & ALLIED

REQUIREMENTS FOR TRAINING & EXAMINATION

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 THIS IS AN EVOLVING DOCUMENT
The College of Physicians and Surgeons Pakistan
would appreciate any criticism, suggestions, advice from the
readers and users of this document. Comments may be sent in
writing or by e-mail to the CPSP at:

DIRECTORATE OF NATIONAL RESIDENCY PROGRAM (DNRP)

College of Physicians and Surgeons Pakistan (CPSP)
7th Central Street, Defence Housing Authority, Karachi-75500.
[email protected]
 CONTENTS

ABOUT THE COLLEGE 01

REGULATIONS FOR TRAINING AND EXAMINATION 04

COMPONENTS OF TRAINING 06

TRAINING PROGRAMME 08

CURRICULUM FOR BASIC SURGICAL TRAINING 17

SYLLABUS 22

PROCEDURAL COMPETENCIES 27

ASSESSMENT 41
 ABOUT THE
COLLEGE
The College was established in 1962 through an ordinance
of the Federal Government. The objectives/functions of the
College include promoting specialist practice of Medicine,
Obstetrics & Gynaecology, Surgery, Dentistry, and other
specialties by securing improvement of teaching and training,
arranging postgraduate medical, surgical and other specialists
training, providing opportunities for research, holding and
conducting examinations for awarding College diplomas and
admission to the Fellowship of the College.
Since its inception, the College has taken great strides in
improving postgraduate medical and dental education in
Pakistan. Competency based structured Residency Programs
have now been developed, along with criteria for accreditation
of training institutions, and for the appointment of supervisors
and examiners. The format of examinations has evolved over
the years to achieve greater objectivity and reliability in
methods of assessment. There cognition of the standards
of College qualifications nationally and internationally,
particularly of its Fellowship, has enormously increased the
number of residents, and consequently the number of training
institutions and the supervisors. The rapid increase in
knowledge base of medical sciences and consequent
emergence of new subspecialties have gradually increased the
number of CPSP fellowship disciplines to sixty nine.
After completing two years of core training during IMM, the
residents are allowed to proceed to the advance phase of FCPS
training in the specific specialty of choice for 2-3 years.
However, it is mandatory to qualify IMM examination before
taking the FCPS-II exit examination. The work performed
by the resident is to be recorded in the e-Iog book on daily
basis. The purpose of the e-Iog is to ensure that the entries are
made on a regular basis and to avoid belated and fabricated
entries. It will hence promote accuracy, authenticity and
vigilance on the part of residents and the supervisors.

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 The average number of candidates taking CPSP examinations
each year around 23,000. The College conducts examinations
for FCPS-I (11 groups of disciplines), IMM, FCPS II (74
disciplines), MCPS (22 disciplines), including MCPS in HPE and
MCPS in HCSM. A large number of Fellows and senior medical
teachers from within the country and overseas are involved at
various levels of examinations of the College.
The College, in its endeavor to decrease inter-rater variability
and increase fairness and transparency, is using TOACS (Task
Oriented Assessment of Clinical Skills) in IMM and FCPS-II
Clinical examinations. Inclusion of foreign examiners adds to
the credibility of its qualifications at an international level.
It is important to note that in the overall scenario of health
delivery over 85% of the total functioning and registered health
care specialists of the country have been provided by the CPSP.
To coordinate training and examination, and provide assistance
to the candidates stationed in cities other than Karachi, the
College has established 14 Regional Centers (including five
Provincial Headquarter Centers) in the country. The five
Provincial Headquarter Centers, in addition to organizing the
capacity building workshops/short courses also have facilities
of libraries, I.T, and evaluation of synopses and dissertations
along with providing guidance to the candidates in conducting
their research work. The training towards Fellowship can be
undertaken in more than 229 accredited medical institutions
throughout the country and 69 accredited institutions abroad.
The total number of residents in these institutions is over
23,927, who are completing residency programs with around
3,708 supervisors. These continuous efforts of the College
have even more importantly developed a credible system of
postgraduate medical education for the country. The College
strives to make its courses and training programs ‘evidence’ and
needs ‘based’ so as to meet international standards as well as to
cater to the specialist healthcare needs not only for this country
but also for the entire region.

Prof. Zafar Ullah Chaudhry

President
College of Physicians and Surgeons Pakistan

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INTERMEDIATE MODULE
To ensure better training, CPSP introduced an Intermediate
Module Examination in several disciplines in 2001. This
mid-training assessment strengthens the monitoring and
in-training assessment systems by providing residents with
an estimate of mid-training competence. It also serves as a
diagnostic tool for residents and supervisors, provides a
curricular link between basic and advanced training, and an
opportunity for sampling a wider domain of knowledge and
skills.

Vide Notifications No. 6-1 / Exam-04 / CPS / 1438 S and R,

the Intermediate Module (IMM) examination is mandatory
eligibility requirement for all FCPS II examinations as from
September 2007 onwards. Residents are required to complete
two years training in Surgery attend all mandatory workshops
and take the Intermediate Module (IMM) examination.

In case of failure in Intermediate Module examination, the

residents are permitted to continue their training in the chosen
specialty but must pass the Intermediate Module examination
prior to appearing in the final FCPS II examination. 

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 REGULATIONS FOR
TRAINING AND
EXAMINATION

GENERAL REGULATIONS
Candidate will be admitted to the examination in the name
(surname and other names) as given in the MBBS degree. CPSP
will not entertain any application for change of name on the
basis of marriage/ divorce / deed.

REGISTRATION AND SUPERVISION

All training must be supervised, and residents are required
to register with the Registration and Research Cell (R&RC),
formerly Registration and Research Cell (R&RC) within 30 days
of starting their training for Intermediate Module. In case of
delay in registration, the start of training will be considered
from the date of receipt of application by the R&RC.
Registration forms are available in R&RC and in the regional
centers. They can also be downloaded from the CPSP website.
Training is compulsorily supervised by an approved supervisor
who is a CPSP fellow or a specialist with relevant postgraduate
qualifications registered at the R&RC. The residents are not
allowed to work simultaneously in any other department/
institutions for financial benefit and/or for other academic
qualifications.

APPROVED TRAINING CENTRES

Training must be undertaken in units, departments and
institutions approved by the College. A current list of approved
institutions is available from the College and its regional
centres as well as on the College website: www.cpsp.edu.pk

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INDUCTION
As per, CPSP Notification No. F.1-1 / Exam-13 / CPSP 367-D
dated October 30, 2013:
Candidates are required to specify at the time of registration,
whether they will pursue straight fellowship in Surgery or
would like to join group A or B during Intermediate Module
(IMM). The scheme of Group A and Group B is given below:

GROUP A GROUP B
• Neurosurgery • Cardiovascular Surgery
• Orthopaedics/ Trauma • Orthopaedics/ Trauma
• Plastic Surgery • Paediatric Surgery
• Urology • Thoracic Surgery

Candidates will be eligible to pursue Post-IMM (FCPS II)

training in any of the specialty of the opted group(A/B), subject
to availability of residency slot in an accredited institution.
No change of group is allowed after induction.  

DURATION
The duration of training for the Intermediate Module (IMM)
is two years; and residents become eligible to appear in
Intermediate Module examination upon completion of IMM
training

ROTATIONS
• 03 months of rotation in Orthopaedics/Trauma is
mandatory for all residents (Surgery, Group A & Group B)
• The residents in straight fellowship in Surgery shall do
three rotations of 02months each in any of the
following specialties: Cardiovascular Surgery,
Neurosurgery, Paediatric Surgery, Plastic Surgery, Thoracic
Surgery and Urology.
• The residents in groups A and B will complete rotations
of 02 months each in the three specialties included in
the opted group except Orthopaedics/Trauma, which they
would complete as mandatory rotation.

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 COMPONENTS OF TRAINING
Mandatory Workshops
It is mandatory for all Intermediate Module residents to attend
following CPSP certified workshops during the two years of
Intermediate Module training:
1. Introduction to Computer and Internet
2. Research Methodology and Dissertation Writing
3. Primary Surgical Skills
4. Communication Skills
5. Basic Life Support (BLS) Course

Any other workshop/s as may be introduced by CPSP.

NOTE: 1) The workshops are conducted by the Department

of Medical Education and the candidates are advised to get
registered online. The BLS course is conducted by the Advanced
Skills Department (ASD) and the registration form is to be
submitted with the ASD separately.

2) No candidate will be allowed to appear in IMM examination

without attending the abovementioned workshops and BLS
course. 

E-logbook
The CPSP council has made e-logbook system mandatory
for residents of all residency programs inducted from July
2011. Upon registration with R&RC each resident is allotted a
registration number and a password to log on to the e-logbook
on the CPSP website. The resident is required to enter all work
performed and the academic activities undertaken in the
logbook on daily basis. The concerned supervisor is required
to verify the entries made by the resident. This system ensures
timely entries by the resident and prompt verification by the
supervisor. It also helps in monitoring the progress of residents
and vigilance of supervisors.

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Workplace Based Assessment (WBPA)
Workplace based assessment tools like Mini-CEX and DOPS are
being used by CPSP for formative assessment. The Faculty of
Surgery has identified areas of Mini-CEX and DOPS for each
quarter of training. Supervisors and residents are advised to
arrange and complete WPBA assignments according to the
timeline mentioned in the competency tables (page 27 onwards
in this curriculum), by uploading the respective Performa at the
end of each quarter.

MINI-CEX
history taking demonstrate the art of 1st quarter
history taking in surgical practice
general physical performs general physical 2nd quarter
examination examination systematically
abdominal performs abdominal 3rd quarter
examination examinations following
standard guidelines
lump examination demonstrate correct steps of 4th quarter
examination of a lump in a real
patient
cervical lymph performs cervical lymph nodes 5th quarter
node examination examination correctly in a real
patient
hernia applies correct clinical methods 6th quarter
examination in the examination of hernia in a
real patient
DOPS
skin suturing demonstrate skills for skin 1st quarter
suturing in a real patient
tru-cut biopsy performs tru-cut biopsy in a real 2nd quarter
patient safely
cvp line performs cvp line insertion in a real 3rd quarter
placement patient safely
chest intubation performs chest intubation in a real 4th quarter
patient safely
lump excision performs excision of lump in a real 5th quarter
patient safely
incision and performs incision and 6th quarter
drainage of an drainage in a real patient correctly
abscess and safely

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 Research (Dissertation / Two Papers)
One of the training requirements for fellowship residents is a
dissertation or two research papers on a topic related to the
field of specialization. For residents of General Surgery the
synopsis of dissertation or research papers must be submitted
to Research and Evaluation Unit (REU) in the first year of the
Intermediate Module. Residents going to subspecialty (Group
A&B) must submit the synopsis in first year of training of the
subspecialty (i.e. 3rd year of FCPS training).

Training Progression
Training should incorporate the principle of gradually
increasing responsibility, and provide each resident with a
sufficient scope, volume and variety of experience in a range
of settings that include inpatients, outpatients, emergency and
intensive care.  

Instructional Methodology
Teaching occurs using several methods that range from formal
didactic lectures to planned clinical experiences. The learning
domains include knowledge, skills, attitudes and practices
relevant to the discipline. College of Physicians and Surgeons
Pakistan has developed its own competency model as follows.

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 TRAINING
PROGRAMME

CURRICULUM: AIMS AND OBJECTIVES

The aim of the residency training programme is to produce

specialists in the field who have attained the required CPSP
competencies. By the end of the residency programme, the
graduates will be able to:
• Take appropriate histories
• Demonstrate proficiency in the requisite physical
examinations
• Justify the ordering and interpretation of tests and
investigations
• Appropriately diagnose, and rule in and rule out contending
conditions
• Manage the problem in a cost effective manner
• Apply the requisite knowledge and skills to think critically
and solve problems
• Be an effective team player, leading the team if necessary
• Communicate effectively with, for example
• Patients and their attendants with empathy and
compassion, in interviewing, counseling, breaking bad
news, behavioural modification and shared
decision-making, recognizing the impact of the
condition on the patients and their families
• seniors, peers, juniors, learners and other health
professionals
• Demonstrate risk analysis and emphasis on prevention
• Ensure patient safety
• Manage emergencies related to the specialty
• Present well in the clinics, rounds and conferences
• Document concise and accurate histories, prescriptions,
progress notes, discharge summaries and referrals
• Keep up to date and practice evidence based medicine
• Demonstrate putting patients first
• Demonstrate Honesty, integrity and timeliness (punctuality
and task completion)

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 • Maintain confidentiality, patient autonomy, take
appropriate consent and do no harm
• Consults with colleagues and refers as necessary
• Demonstrates effective teaching and mentoring skills for
juniors and for other members of the health care teams
• Exhibit Advocacy for their patients, practice (service/
department), profession (discipline/specialty) and
population-based problems related to their specialty
• Initiate/participate in/expand clinical governance and
clinical audit
• Recognize and resolve stress in self and others
• Demonstrate a sound research study, and the use of
research in improving clinical practice
• Demonstrate willingness to accept critique constructively
• Demonstrate willingness and the ability to adapt and
change as per changing circumstances and changing
technology
• Demonstrate conflict resolution, management skills and
leadership
• Maintain the highest standards of practice

The competencies outlined above have been reflected in the

Competency model of the CPSP as depicted below:

CPSP COMPETENCY MODEL

College has moved towards competency based medical
education and developed its own outcomes / competency
model.

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With patient or population care as the pivotal center, the inner
leaves of the model represent the five major competencies
directly related to patient care, while the three competencies in
the outer circle are mega-competencies related to patient care
and also incorporate education, professionalism, leadership,
advocacy and population health.

By the end of the Residency Programme, residents are

expected to acquire these competencies and their constituent
learning outcomes, and provide promotive, preventive, curative
and rehabilitative patient-centered (or population-centered)
care.

Inner Leaves:
1. Knowledge and Critical Thinking
2. Technical Skills
3. Communication Skills
4. Teamwork
5. Research

Outer Leaves:
6. Professionalism
7. Advocacy
8. Pedagogy

1. Knowledge and Critical Thinking

• Demonstrate application of wide and current readings to
critical thinking and problem solving.
• Relate the alteration of body function to the presenting
condition.
• Interpret and integrate history and examination findings to
arrive at an appropriate provisional and credible
differential diagnoses.
• Sequentially order, justify and interpret appropriate
investigations;
• Apply knowledge and reasoning skills to
• Analyze data for problem identification and to rule in
and rule out contending conditions
• Synthesize and evaluate solutions for decision-making
in solving familiar and less familiar problems based on

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 best current evidence.
• Prioritize different problems within a time frame.
• Select, outline and provide, with evidence-based
justifications, appropriate pharmacological and
non-pharmacological management strategies
• Assess new medical knowledge and apply it to resolve
patient problems (Evidence-based practice).
• Apply quality assurance procedures in daily work. (Pro
fessionalism)
• Demonstrate shared-decision-making with the patient
or family;
• Provide cost-effective care while ordering
investigations
and in management
• Use resources appropriately
• Demonstrate awareness of bio-psycho-social factors in
assessment and management of a patient.

2. Technical Skills
• Obtain an accurate history with sensitivity;
• Perform an accurate physical and mental state
examination, even in patients with complex health
problems involving multiple systems;
• Demonstrate International Patient Safety Goals (IPSG)
• Demonstrate competent performance of all required
technical skills and procedures in their specialty, including:
• Obtaining informed consent
• Preoperative planning
• Pre-interventional care and preparation
• Intra-Intervention technique including exposure and
closure, global and task specific items, and
communication and team skills
• Post-interventional care
• Follow-up Care

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3. Communication Skills
• Written Communication Skills
• Maintain clear, concise, accurate and updated medical
records.
• Write clear, focused, evidence-based and logical
management plans and discharge summaries.
• Write respectful, clear and focused letters and referrals
to other colleagues.

• Verbal Communication Skills: Demonstrate

• Effective interpersonal communication skills: clear,
considerate and sensitive towards patients, their
relatives, other health professionals and the public, and
towards students.
• Non-verbal communication skills:
• Empathy and respect towards patients and their
relatives.
• Effective counseling of the patient and the family with
cultural sensitivity: explain options, educate them and
promote joint decision-making.
• Appropriate verbal and body language on the campus
and all work situations including seminars, bedside
sessions, outpatient sessions and others.
• Respect and tolerance for all health care professionals,
including peers, juniors and seniors.
• Clear, focused and logical presentation of cases.

4. Teamwork
• Demonstrate constructive team-communication skills.
• Facilitate collaborative group interaction as a team mem-
ber to build strong teams demonstrating respect, tolerance
and interdependence.
• Support other team members to grow.
• Demonstrate willingness to assume responsibility and
leadership as needed.

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 5. Research
• Interpret and use results of various research studies
(critical appraisal).
• Conduct a research study individually or in a group by
using appropriate
• Selection of research question(s) and objectives
• Research design and statistical methods to answer the
research question.
• Ethical and R&RC approval of the synopsis
• Demonstrate competence in academic writing by writing
an appropriate dissertation and/or publishing research
article(s) as a step towards resolving issues or concerns in
their specialty.
• Guide others in conducting research by advising about
research methodology including study designs and
statistical methods.
• Demonstrate clear, focused and logical presentations of
their research.

The outer leaves of the model consist of three mega

competencies and each of these consist of multiple elements.
6. Professionalism
7. Pedagogy
8. Advocacy

6. Professionalism, Ethics and Leadership: The resident should

be able to:

Professionalism
• Demonstrate the highest level of personal integrity:
honesty, punctuality, regularity, timely task completion.
• Deal with all patients in a non-discriminatory and
prejudice- free manner, demonstrating the same level of
care for every human being irrespective of gender, age,
ethnic background, culture, socioeconomic status and
religion.
• Establish a trusting relationship with patients, their
relatives and care-givers.
• Deal with all patients with honesty, empathy and
compassion, putting patients’ needs first (altruism)

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• Facilitate transfer of information important for promotion
of health, prevention and management of disease.
• Encourage questioning by the patient and be receptive to
feedback.
• Pursue self-directed and life-long learning. Keep abreast
of medical literature and assess new knowledge and apply
it to resolve patient problems.
• Know one’s limitations and ask for help as needed from
colleagues, consultations or referrals.
• Apply quality assurance procedures for improvement in
daily work.
• Be a role model for others

Ethics
• Maintain patient autonomy by demonstrating shared-
decision-making with the patient and/or family.
• Obtain informed consent, maintain patient confidentiality
and do no harm.
• Provide cost-effective care while ordering investigations
and in management and use resources appropriately.
Leadership
• Demonstrate accountability for their decisions and actions,
and that of their team.
• Demonstrate willingness to assume leadership role(s)
when needed in given situations or events (rush call/code).
• Change and bring about change as necessary, as a leader
or supportive leader.

7. Pedagogy
Should be able to demonstrate competence in teaching skills:
• Effective clinical/community-based teaching
• Some evidence of acquisition of theory regarding learning
and education
• Practice some of the best teaching methods.

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 8. Advocacy
Advocacy is needed at multiple levels
• Advocacy for the Patient:
• Doctors and nurses are the advocates of the patients,
otherwise patients are likely to be lost in the system.
All care should be timely, putting patients first.

• Advocacy for the Practice

• Working in a service or practice, doctors must highlight
limitations and issues.
• They must identify solutions for the problems, and
recommend and implement improvements for the
practice(s) and institutional system(s).

• Advocacy for the Health System and Society

• Know one’s role in the Health System(s) and build
strong referral systems.
• Keep patient and community interests paramount,
above one’s own personal or professional interest.
• Demonstrate advocacy for elimination of the social
determinants of health.
• Demonstrate advocacy for prevention of serious
illnesses of their specialty/sub-specialty.

• For the Profession

• Strive for building trust in the public for your
profession.
• Demonstrate improvement and enhancement of
profession, specialty and sub-specialty.
• Be conscientious gate-keepers of their profession,
specialty and subspecialty.

In order to achieve the competencies of CPSP model, all

curriculum components including instructional methods should
be appropriately aligned to competency network.

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The theoretical part of the curriculum represents the current
body of knowledge necessary for practice. This can be imparted
through lectures, grand teaching rounds, clinico-pathological
meetings, morbidity/mortality review meetings, literature
reviews and presentations, journal clubs, self directed learning,
conferences and seminars.

Clinical learning is to be organized to provide appropriate

expertise and competence necessary to evaluate and manage
common clinical problems. Demonstration in outpatient and
inpatient clinics, and procedural skills training on simulators,
mannequins and patients are all practical training modalities.
 

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 CURRICULUM FOR BASIC SURGICAL TRAINING

GOALS
Upon completion of training in intermediate module in
Surgery and allied, a resident must acquire the basic
competencies in the principles and practice of surgery along
with outcomes in the domains of knowledge, skills and attitude
in order to:
• Provide appropriate and cost-effective care to patients at
all levels.
• Promote health and prevent disease in patients, families
and communities.
• Practice continuing professional development.
• For this purpose the resident must acquire:
• Knowledge and expertise in clinical and procedural
management of relevant diseases.
• Basic surgical skills.
• Effective clinical judgment and decision making in
dealing with surgical problems using evidence based
medicine.
• The coverage that each discipline receives below is not
indicative of the relative importance placed on each
discipline in the training program, or in the examination.
These are guidelines and not comprehensive definitive
lists. Only minimum levels of expected competence have
been identified but sufficient scope, volume and variety of
experience are desirable. 

OUTCOMES
Upon completion of Intermediate Module in Surgery, the
resident is able to:
• Plan Preoperative care of surgical patients:
• Evaluate the metabolic response to surgery and
infection
• Assess fitness of patients for Surgery and Anesthesia
• Assess risks involved in surgery
• Test for respiratory, cardiac and renal functions
• Manage patients with associated medical disorders

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• Manage post operative patients:
• Prescribe appropriate analgesics for postoperative
pain control
• Take appropriate measures to prevent postoperative
complications
• Diagnose postoperative complications
• Manage postoperative complications effectively

• Understand and demonstrate basic principles of surgical

craft and theatre technology:
• Understand the principles of antisepsis, sterilization
and concept of aseptic surgery
• Demonstrate correct methods of scrubbing, gowning
and gloving
• Demonstrate use of common surgical instruments and
appliances (suction, diathermy, retractors, general
instruments)
• Identify appropriate uses of suture and ligature
materials
• Understand basic principles of anastomosis
• Demonstrate various techniques of biopsies: needle
aspiration, trucut, open
• Discuss the uses of tourniquet and precautions
regarding its application 
• Discuss the principles involved in various types of
anesthesia: Local, Regional and General Anesthesia
• Monitor patient during anesthesia
• Distinguish between analgesia and sedation

• Understand the impact of infection in surgery:

• Describe surgically important micro-organisms
• Identify sources of surgical infections and take
effective measures for their prevention and control
(asepsis and antibiotic usage)
• Discuss body’s response to infection
• Use appropriate methods for carrying out surgery in
hepatitis and HIV carriers

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 • Demonstrate appropriate wound management:
• Classify surgical wounds
• Describe pathophysiology and principles of wound
healing
• Describe principles and methods of wound
debridement and closure
• Describe mechanisms of scar and contracture
formation
• Manage the surgical wounds appropriately

• Resolve nutritional problems in surgical patients:

• Assess nutritional status of patients
• Prescribe nutritional values and components of
different enteral and parenteral food preparations
• Select different routes of nutrition administration
based on indication/limitations

• Correct fluid, acid base and electrolyte imbalances:

• Describe physiological processes contributing to fluid,
acid base and electrolyte balance
• Describe principles of fluid and electrolyte
replacement
• Discuss etiology and mechanism of shock
• Assess and manage various types of hemorrhage
• Manage shock
• Describe indications and hazards of blood transfusion
• Prescribe blood products and their substitutes 

• Manage critically ill patients:

• Diagnose and manage an unconscious patient
• Operate monitoring devices and interpret their
findings
• Describe etiological factors for cardiac arrest
• Resuscitate patients with cardiac arrest
• Discuss various ionotropic agents
• Identify features of brain death

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• Manage individual and mass Trauma by attaining
following competencies:
• Understand Epidemiology of trauma
• Understand and demonstrate initial assessment and
resuscitation of a traumatised patient including:
• Primary and secondary survey
• Airway clearance and ventilation of patient
requiring assisted respiration
• Management of hemorrhage and shock
• Application of Principles of triage
• Management of:
• Thoracic trauma
• Abdominal and pelvic trauma
• Head and spine trauma

• Management of limb trauma including fractures,

tendon and nerve injuries
• Factors, etiology and principles of healing of soft
tissues, tendon and bone
• Immobilization and fixation
• Fracture and its complications
• Compartment syndrome, crush syndromes, fat
embolism, fasciotomy
• Neurological and vascular injuries in limb trauma

• Understand, assess and manage head injuries

• Order and prepare for appropriate imaging according to

their indications and limitations
• Plain and contrast X-rays, Ultrasound examination,
CT Scan etc.

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 • Communicate and collaborate effectively:
• Establish professional relationships with patients and
families.
• Discuss/counsel appropriate information with patients
and families, and the health care team.
• Consult effectively with other physicians and health
care professionals.
• Demonstrates appropriate respect for health care team
• Demonstrates appropriate respect for seniors, juniors

• Practice Teaching
• Demonstrate the ability to teach medical
students, interns, other residents and allied health
care staff.

• Practice Professionalism:
• Deliver high standard quality care with integrity,
honesty and compassion.
• Exhibit appropriate interpersonal professional
behavior.
• Practice of medical profession according to
established ethical norms.
• Ethics EBM upto date

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SYLLABUS
PRINCIPLES & PRACTICE OF SURGERY
• Surgical infections
• Principles of wound healing
• Hemorrhage & control / resuscitation
• Sterilization and disinfection
• Fluid & electrolytes
• Perioperative care (Pre-op, Post-op) Cirrhosis, DM, HTN,
IHD, Renal failure, Jaundice)
• Blood & products & shock
• Antibiotics
• Clinical features & investigations of vascular disorders
(CLl)
• Clinical features & investigations of lymphatic disorders
• Nutrition
• Specific infection tetanus, gas gangrene, TB, typhoid, Hep
B,C, AIDS, synergistic growing etc.
• Tissue diagnosis
• Diagnostic imaging principles
• Principles of anastomosis & basic surgical skills
• Principles of Gl endoscopy
• Principles of MIS
• Principles of pain management
• Principles of L/A, regional G G/A
• Metabolic response to trauma
• Principles of stoma management (Fistula - (Poster) / short
gut syndrome
• Palliative care - Principles
• Principles of surgical oncology (Lumps of skins and
subcutaneous tissue)
• Principles of burn management
• Principles of surgery in extremes of ages (Pediatric &
Geriatric)
• Principles of plastic surgery (grafts, flaps, scars, pressure
sores, VAC dressing)
• Principles of thoracic surgery
• Indications, management & complications of tube
thoracotomy, pneumothorax, chest pain)
• Chest physiotherapy

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 • Principles of urologic surgery
• Principles & management of acute & chronic urinary
retention, hematuria, UTI
• Clinical features of BPH
• Abdominal wall and groin hernia
• Principles of transplant surgery
• Indications and principles of HDU & intensive care (CCRT)
• Principles & management of diabetic foot
• Hand infection
• Ethics
• Research
• Professionalism
• Principles of managing mass/multiple casualties including
disaster & triage
• Postop complications
• Principles of electro surgery
• Salivary glands, stones and pleomorphic neoplasms

CRITICAL CARE
• Respiratory failure
• Principles of assisted ventilation
• Principles of invasive monitoring (CVP + Arterial)
• Inotropic support
• ARDS
• Principles of acute renal shutdown
• Sepsis
• DIC
• Brain death & end of life decision
• Acid base balance
• ABG analysis
• Nutrition in ICU (critically ill)
• Monitoring of critically ill patient in ICU
• Abdominal compartment
• MODS / MOSF
• Cardiac arrest

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TRAUMA (INITIAL ASSESSMENT & RESUSCITATION ON ATLS
PRINCIPLES} COMMON TO ALL

Orthopedic Bone Healing:

• General principles of fracture management
• Complications of fractures
• Compartment syndrome & Fasciotomy
• Crush syndrome, Fat embolism
• Nerve & tendon injury (principles of diagnosis & treatment)
• Principles & management of front distraction
• Mangled extremity
• Amputations
• Acute & chronic osteomyelitis
• Fracture neck of femur & pathological fractures
• Diagnosis of orthopedic disorders including imaging &
tissue diagnosis
• Management of complicate fractures

Orthopaedic Trauma:
• Polytrauma
• Pelvic fracture
• Fracture neck of femur
• Supracondylar fracture
• Colle’s fracture
• Tibial fracture
• Dislocation of hip
• Dislocation of shoulder
• Principles of management of spinal trauma

25
 Neuro Trauma:
• Head injuries
• Traumatic int. cranial fracture
• ICP monitoring and raised ICP
• Spinal shock
• Neurogenic shock
• Diagnostic imaging
• Secondary brain injury
• Scalp wounds management

Skill:
• Burr hole / craniotomy
• Spinal immobilization
• Cervical spine immobilization
• ICP monitoring

Urogenital Trauma:
• Renal trauma
• Ureteric trauma
• Bladder trauma
• Urethral trauma

Cardiac Trauma:
• Penetrating
• Blunt cardiac injuries
• Pericardial tamponade

Vascular Trauma:
• Peripheral vascular injuries (investigations &
management)

Skill:
• Vascular anastomosis
• Examination of peripheral vascular system (A+ veins)

26
Pediatric Trauma:
• Principles of management of pediatric trauma including
anatomical considerations regarding
• Airway, thoracic, l/V fluid, resuscitation and routes

Skill:
• lntraosseous needle

Thoracic Trauma:
• Penetrating thoracic trauma
• Blank thoracic trauma
• Swabbing wounds
• Tension pneumothorax
• Massive hemothorax
• Diaphragmatic injuries
• Rib fractures
• Flail chest
• Indications and principles of emergency thoracotomy

Skill:
• Needle decompression
• Chest tube insertion
• Thoracotomy
• Occlusive dressing
• Abdominal trauma:
• Solid organ trauma
• Hallow visceral injuries
• Penetrating
• Blunt injury
• Diagnosis - DPL/CT/F - Mini-CEX
• Principles of damage control,
resuscitation and surgery

27
 PROCEDURAL COMPETENCIES

The clinical skills, which a surgeon must have are, varied and
complex. A complete list of the same necessary for residents
and trainers is given below. Some examples, which are a sub
sample of the whole, follow. These are to be taken as guidelines
rather than definitive requirements.Key for assessing
competencies:
1. Observer status.
2. Assistant status.
3. Performed under direct supervision.
4. Performed under indirect supervision.
5. Performed independently

Note: Levels 4 and 5 for practical purposes are almost

synonymous

28
 FIRST YEAR

level cases minicex dops level cases minicex dops level cases minicex dops level cases minicex dops

elicit a pertinent history 5 15 5 15 5 15 5 15 60

communicate effectively with 3 15 3 15 4 15 4 15 60
patients, families and the health team
(observed) 5 15 5 15 60
perform a physical examination 5 15 5 15 4 15 4 15 60
order appropriate investigations 4 15 4 15 3 15 3 15 60
interpret the results of investigations 3 15 3 15 3 15 3 15 60
assess fitness to undergo surgery 2 15 2 15 3 15 3 15 60
decide and implement appropriate 2 15 2 15 3 15 3 15 60
treatment 3 15 3 15 60
postoperative management and 2 15 2 15
monitoring 4 5 4 5 40
maintain accurate and appropriate 3 15 3 15 3 5 3 5 40
records

29
30
FIRST YEAR

level cases minicex dops level cases minicex dops level cases minicex dops level cases minicex dops

use of aseptic techniques 2 5 2 5 4 8 4 8 26

positioning of patient for diagnostics 2 5 2 5 3 3 3 3 16
and operative procedures (variety)
identification and appropriate use of 2 8 3 8 3 3 3 3 22
common surgical instruments, suture
materials and appliances

controlling hemorrhage 2 3 2 3 3 3 4 3 12
debridement, wound excision, 2 3 2 3 3 1 3 1 8
closure/suture of wound (excluding
repair of special tissues like nerves
and tendons)
uretheral catheterization 2 3 3 3 3 1 3 1 8
suprapubic puncture 2 1 2 1 3 2 3 2 6
meatotomy 2 1 2 1 4 4 4 4 10
circumcision 2 2 2 2 3 3 3 3 10
nasogastric intubation 3 4 3 4 3 3 3 3 14
venesection 2 2 2 2 3 1 3 1 6
tube throacostomy 2 3 2 3 3 2 3 4 12
management of empyema 2 1 2 1 3 2 3 2 6
biopsy of lymph nodes 2 2 2 2 3 2 3 2 8
biopsy of skin lesions, subcutaneous 2 2 2 2
lumps or swellings
excision of soft tissue benign tumors 2 2 2 2 2 1 3 1 6
and cysts (surface surgery)
cricothyroidotomy 2 1 2 1 2 1 2 2 5
opening and closing of abdomen 1 1 1 1 3 3 3 3 8
proctoscopy and interpretation of 2 3 2 3 3 1 3 1 8
findings
 FIRST YEAR
09 months
level cases minicex dops level cases minicex dops level cases minicex dops level cases minicex dops

proctosigmoidoscopy 2 1 2 1 3 1 3 1 4
fine needle aspiration (fnac) 2 1 2 1 3 2 3 2 6
removal of skin stitches/staplers 2 2 3 2 3 3 3 3 10
removal of drains/ng tube/foley`s 2 3 3 3 3 1 3 1 8
tru cut biopsy od body surface lesions 1 1 2 1 2 1 2 2 5

inguinal hernia repair 1 1 2 1 2 1 2 1 4

rectal polyp 1 1 2 1 2 2 2 2 6
suprapubic cystostomy 1 1 2 2 2 1 3 1 5
vesicolithotomy 1 1 2 1 2 2 2 3 7
hemorrhoids, fissures, fistulae in ano 1 1 2 2 2 1 2 1 5
exploratory laparotomy 1 1 2 1 2 3 3 3 8
appendicectomy 1 1 2 2 2 1 2 1 5
cholecystectomy 1 1 2 1 2 1 2 1 4
oncological surgery 1 1 2 1 2 1 2 1 4
laparoscopic / endoscopic surgery 1 1 2 1
(principles and instrument handling)
breast operations and benign lesions 1 1 2 1 2 1 3 1 4
stoma formation and reversal 1 2 1 2 1 2 1 3
ventral hernia repair 1 1 2 1 2 1 2 1 4
use of ventilators 1 1 1 1 2 1 2 1 4

31
32
FIRST YEAR

level cases minicex dops level cases minicex dops level cases minicex dops level cases minicex dops

wound healing and peri-operative 1 2 2 2 3 2 3 2 8

complication
cpr 1 1 2 1 2 2 3 2 6
cv lines 1 1 1 1 2 1 2 1 4
fluid and electrolyte balance 2 2 3 2 4 3 4 3 10
monitoring devices 1 2 2 2 2 3 2 3 10
inotropic agents 1 2 2 2 2 3 2 3 10
care of unconscious patient 1 1 2 1 2 1 3 1 4
replacement of nutrition 2 1 3 1 3 1 4 1 4
stoma care 1 1 2 1 2 1 3 1 4

airway maintenance and passing of 1 1 2 1 2 1 3 2 5

endotracheal tube
ippr and other methods of ventilation 1 1 2 1 2 1 3 1 4
local anesthesia 1 1 2 1 2 1 3 2 5
regional anesthesia 1 1 1 1 1 1 2 1 4
lumber puncture and spinal anesthesia 1 1 1 1 1 1 2 1 4
principles of general anesthesia 1 1 1 1 2 1 3 1 4
 topics of minicex and dopS
FIRST YEAR

minicex dops minicex dops minicex dops minicex dops

history taking 1
general physical examination 2
abdominal examination 3
lump examination 4
cervical lymph node examination
hernia examination
4

history taking 1
general physical examination 2
abdominal examination 3
lump examination 4
cervical lymph node examination
hernia examination
4

33
34
SECOND YEAR

level cases minicex dops level cases minicex dops

elicit a pertinent history 5 20 5 20 40

communicate effectively with 5 20 5 20 40
patients, families and the health team (observed) 5 20 5 20 40
perform a physical examination 5 20 5 20 40
order appropriate investigations 4 20 4 20 40
interpret the results of investigations 4 20 4 20 40
assess fitness to undergo surgery 4 20 4 20 40
decide and implement appropriate treatment 4 20 4 20 40
postoperative management and monitoring 4 20 4 20 40
maintain accurate and appropriate records 4 20 4 20 40
 SECOND YEAR

level cases minicex dops level cases minicex dops

use of aseptic techniques 4 10 4 10 20

positioning of patient for diagnostics and operative procedures (variety) 4 10 4 10 20
identification and appropriate use of common surgical instruments, suture materials and 4 15 4 15 30
appliances

controlling hemorrhage 4 5 4 5 10
debridement, wound excision, closure/suture of wound (excluding repair of special tissues 5 5 5 5 10
like nerves and tendons)
uretheral catheterization 5 5 5 5 10
suprapubic puncture 4 2 5 2 4
meatotomy 4 2 5 2 4
circumcision 4 5 5 5 10
nasogastric intubation 4 5 5 5 10
venesection 4 6 5 6 12
tube throacostomy 4 6 5 6 12
management of empyema 3 2 4 2 4
biopsy of lymph nodes 3 5 4 5 10
biopsy of skin lesions, subcutaneous lumps or swellings 3 5 4 5 10
excision of soft tissue benign tumors and cysts (surface surgery) 4 5 5 5 10
cricothyroidotomy 4 2 5 2 4
opening and closing of abdomen 3 5 4 4 10
proctoscopy and interpretation of findings 4 8 4 8 16
proctosigmoidoscopy 4 5 4 5 10
fine needle aspiration (fnac) 3 4 4 4 8
removal of skin stitches/staplers 4 4 5 4 8
removal of drains/ng tube/foley`s 4 4 5 4 8
tru cut biopsy od body surface lesions 3 1 4 1 2

35
36
SECOND YEAR

level cases minicex dops level cases minicex dops

inguinal hernia repair 3 4 4 4 8

rectal polyp 3 3 4 3 6
suprapubic cystostomy 4 4 4 4 8
vesicolithotomy 3 2 4 2 4
hemorrhoids, fissures, fistulae in ano 3 8 4 8 16
exploratory laparotomy 3 3 3 5 8
appendicectomy 4 7 4 8 15
cholecystectomy 3 2 3 2 4
oncological surgery 2 2 2 4 6
laparoscopic / endoscopic surgery (principles and instrument handling) 2 3 3 3 6
breast operations and benign lesions 3 4 4 4 8
stoma formation and reversal 2 1 3 1 2
ventral hernia repair 2 1 3 1 2

use of ventilators 2 2 3 2 4
wound healing and peri-operative complication 4 2 5 2 4
cpr 4 3 5 5 8
cv lines 3 4 4 4 8
fluid and electrolyte balance 5 5 5 5 10
monitoring devices 3 5 4 5 10
inotropic agents 3 5 4 5 10
care of unconscious patient 4 4 5 4 8
replacement of nutrition 4 5 4 8 13
stoma care 3 1 4 1 2

airway maintenance and passing of endotracheal tube 3 6 4 6 12

ippr and other methods of ventilation 3 2 5 2 4
local anesthesia 4 6 5 6 12
regional anesthesia 2 2 3 2 4
lumber puncture and spinal anesthesia 2 2 3 2 4
principles of general anesthesia 3 1 4 1 4
 topics of minicex and dopS
SECOND YEAR

minicex dops minicex dops

history taking
general physical examination
abdominal examination
lump examination
cervical lymph node examination 5
hernia examination 6
2

history taking
general physical examination
abdominal examination
lump examination
cervical lymph node examination 5
hernia examination 6
2

37
38
closed treatment of common fractures 1,2 5,5
open reduction, external fixation 1,2 5,5
operation on tendons (repair and lengthening) 1,2 5,5,2
nerve repair 1,2 5,5,2
application of splints, pop casts and skin tract 1,2,3 5,5,5,5
amputation 1,2,3 5,5,1
management of compound fractures 1,2 5,5
faciotomy 1,2,3 4,4,2
bone biopsy 1,2 1,1
removal of pop cast 1,2,3 1,1, 1
diagnosis and management of compartment syndrome 1,2 1,1

burr hole for cerebral decompression 1,2 5,5

intracranial operations 1,2 5,5
spinal decompression surgery 1,2 5,5,2
specialized care of head injury 1,2,3 5,5,2
application of cervical collar 1,2,3 2,1,1
log roll of patient 1,2,3 1,1,1
 needle thoracostomy 1,2,3 3,3,3
tube thoracostomy 1,2,3 2,2,2
thoracotomy (opening & closing) 1,2 1,1
diagnosis and management of life threatening chest 1,2,3 1,1,1
trauma (tension pneumothorax, open pneumothorax,
massive haemothorax, flail chest)

burn care 1,2,3 5,5

cleft lip congenital deformities 1,2 2,2
cleft palate congenital deformities 1,2 2,2
repair of deformities including release of contractures 1,2 1,1
hypospadia repair 1,2 1,1
free flaps 1,2 1,1

39
40
circumcision in infants 1,2,3 1,1,1,1
fluid and electrolyte requirement 1,2,3 1,1,1
manage perioperative hernias 1,2,3 1,1,2
orchedopexy 1,2 1,2
imperforate anus operations 1,2 1,1
trachea-esophageal fistula 1,2 1,1
rectal polypectomy 1,2,3 1,1,1
inguinal herniatomy 1,2,3 1,1,1

management of acute retention of urine 1,2,3 1,1,1

vesicolithotomy 1,2,3 1,1,1
kidney & ureter operations 1,2 2,2
percutaneous nephrolithotomy (pcnl) 1,2 1,1
eswl 1 2
ureteorenoscopy (urs) 1,2 1,1
turp 1,2 1,1
turbt 1,2 1,1
cystoscopy 1,2 1,1
insertion and removal of dj stent 1,2 1,1
urethroplasty 1,2 1,1
varicocelectomy 1,2 1,1
hydrocelectomy 1,2 1,1
orchidectomy 1,2 1,1
ASSESSMENT
ELIGIBILITY REQUIREMENTS
For appearing in Intermediate Module examination a candidate
should have:
• Passed FCPS I in Surgery and Allied Disciplines or granted
exemption.
• Registered with the Registration & Research Cell (R&RC).
• Completed two years of training under an approved
supervisor in an institution recognized by the CPSP. A
certificate of completion of training must be submitted.
• Completed entries in e-logbook along with validation by
the supervisor.
• Submitted certificates of attendance of mandatory
workshops.
• Should have submitted synopsis of dissertation or abstract
of research articles.

EXAMINATION SCHEDULE
• The Intermediate Module theory examination will be held
twice a year.
• Theory examinations are held in various cities of the
country usually at Abbottabad, Bahawalpur, Faisalabad,
Hyderabad, Islamabad, Karachi, Nawabshah, Larkana,
Lahore, Multan, Peshawar and Quetta centres. The College
shall decide where to hold TOACS examinations depending
on the number of candidates in a city and shall inform the
candidates accordingly.
• English shall be the medium of all examinations for theory
and TOACS.
• The College will notify of any change in the centres, the
dates and format of the examination.
• A competent authority appointed by the College has the
power to debar any candidate from any examination if it is
satisfied that the candidate has indulged in unfair practices
in College examination, misconduct or because of any other
disciplinary reason. 

41
 EXAMINATION FEE
• Fee deposited for a particular examination shall not be
carried over to the next examination in case of withdrawal,
absence or exclusion.
• Applications along with the prescribed examination fee
and required documents must be submitted by the last
date notified for this purpose before each examination.
• The details of examination fee and fee for change of centre,
subject, etc. shall be notified before each examination.

REFUND OF FEES
If after submitting an application for examination, a candidate
decides not to appear, a written request for a refund must be
submitted before the last date for withdrawal with the receipt
of applications. In such cases a refund is admissible to the
extent of 75% of fees only. No request for refund will be
accepted after the closing date for receipt of applications for
refund.
If an application is rejected by the CPSP, 75% of the
examination fee will be refunded, the remaining 25% being
retained as a processing charge. No refund will be made for fees
paid for any other reason, e.g. late fee, change of centre/subject
fee, etc.

FORMAT OF EXAMINATION
Intermediate Module examination consists of the following
components:

Theory Examination:
It is a computer based examination consisting of two papers
Paper-I: 100 MCQs of Single Best Type
Paper-II: 100 MCQs of Single Best Type

Paper-I will be common for all trainees of IMM surgery and shall
cover course content comprising of Principals and Practice of
Surgery.

Guidelines for solving Paper-II

Paper-II consists of two parts, ‘A’ and ‘B’. Part ‘A’ contains 40
questions and it is mandatory for all candidates to attempt this
part.

42
Part ‘B’ consists of six blocks of sub-specialties containing 20
questions in each. Candidates of all groups (A, B & straight)
are allowed to attempt any three blocks, irrespective of their
rotations.

Sub-Specialties Included in Part-B

• Urology 20 MCQs
• Paediatric Surgery 20 MCQs
• Thoracic Surgery 20 MCQs
• Plastic Surgery 20 MCQs
• Neurosurgery 20 MCQs
• Cardiovascular Surgery 20 MCQs

In total, 100 questions will be attempted by each candidate, 40

from Part A and 60 from Part B.

Clinical Examination:
To test basic clinical skills, the clinical examination consists of:
TOACS (Task Oriented Assessment of Clinical Skills) Only those
candidates who qualify in the theory will be eligible to take the
TOACS examination.
TOACS will comprise of 12 to 20 stations with a minimum
duration of 6 minutes and change over time of one minute for
the candidate to move from one station to the other.
TOACS shall be same for all residents and shall be based on core
competencies covering basic clinical and procedural skills, life
supporting skills and communication skills. It will also include
one station on research synopsis and other on e-log. There
will be two types of stations: static and interactive. On
static stations the candidate will be presented with patient data,
a clinical problem or a research study and will be asked to give
written responses about the questions asked. At the interactive
stations the candidate will have to demonstrate a competency,
for example, taking history, performing a clinical examination,
counseling. One examiner will be present at each interactive
station and will either rate the performance of the candidate
or ask questions testing reasoning and problem solving skills.
College is encouraging to have all stations to be interactive
and expects that the static stations will soon be phased out.

43
Pubished 13Th December 2019

COLLEGE OF PHYSICIANS AND SURGEONS PAKISTAN

7th Central Street, Defence Housing Authority, Karachi-75500.
Phone No. 9926400-10, UAN: 111-606-606, Fax No. 99266432