Best Tips for Honoring your Surgery Clerkship

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Surgery is a challenging but rewarding specialty and you should expect your clerkship to be the same. Surgery is also unlike other specialties you will rotate through and if you want to receive honors, you will need to take a different approach than you did for other clerkships. You will have to work hard, but your hard work will be rewarded. These tips will help you maximize your educational opportunities in surgery and achieve honors.

 

Set Expectations for Your Surgery Clerkship

 

On your first day, ask your chief resident about the expectations they have for medical students. Tell them that you want to learn and be involved as much as possible. Be enthusiastic. Do not tell them you want to be a surgeon unless it is true. Make sure you follow any expectations they set for you. 

 

Show Up Early

 

You should plan to be at the hospital before anyone on your team, including the intern. Getting there early will give you enough time to review patient charts and pre-round on your patients before the rest of the team arrives. You should also get a sign-out from the overnight resident on all patients and write it down. On your first or second day, ask the intern to help with numbers (vitals and labs), and continue to get the numbers every morning until the end of your rotation. You will make copies for the rest of the team. Normally interns are expected to do this but helping the intern will reflect well on you as a medical student. Furthermore, you can start writing the progress notes on your patients, as you may not have much time after rounds to complete them. 

 

See Your Surgery Clerkship Patients

 

You should pre-round on your patients before your team. When you see your patients, make sure to examine them. An abdominal exam is especially important for most surgical services. Ask the nurses about overnight events for your patients. Sometimes things are not documented in the chart. 

 

Master the Surgical Patient Presentation

 

As you have probably already heard, surgery rounds are quick, and it is unlikely that your chief resident or attending will want to hear a lengthy presentation like you would give on almost every other clerkship. With that said, presenting your patients is one of the rare times when you have a chance to impress your chief and attending surgeon. Start your presentation by stating the patient’s age and gender, post-operative day, and surgery. Next, give a quick subjective. For surgical patients, always ask about bowel movements and flatus. We want to know when their bowel function returns after abdominal surgery.

 

Next up are vitals, physical exam, Ins and Outs, and pertinent labs. For any numbers, talk about trends, and not just one morning’s number. For example, “hemoglobin is 8 from 9 (yesterday’s) and has been trending down over the last few days.” Note the trend in urine output and drain outputs as well. Finally, you should have an assessment and plan. This is the most difficult part, but you must always have a plan. It is better to have a plan that is wrong than not have one at all. This shows that you are thinking clinically. If you have time prior to rounds, run your plan by the intern or junior resident on the team. They will help you improve it. Finally, be confident as you present. 

 

Example Surgery Patient Presentation:

  1. Describe who the patient is (38 y/o female with small bowel obstruction, post-operative day #2 s/p ex lap)
  2. Subjective – how the patient is progressing (still no BM or flatus, tolerating clear liquid diet)
  3. Vitals and physical exam (Vital signs are stable – don’t say normal, abdomen distended with no tenderness or rebound)
  4. Ins and Outs, including drain/tube output, pertinent labs (NG output = 500 cc compared to 1500 yesterday, hemoglobin down to 8 from 9.2)
  5. Assessment and Plan (38 y/o female POD 2 s/p ex lap, has not had return of bowel function, and with downtrending hemoglobin. I would like to rule out bleeding, so I will obtain another CBC in the afternoon, keep NPO, and perform serial abdominal exams)

 

Prepare for Your Surgery Clerkship Cases

 

This is one of those other rare times where you will get the opportunity to impress the attending surgeons when they “pimp” you in the operating room. Ask your chief the day before what cases you will be scrubbing the next day. Read about the patients, especially their pre-operative notes. Then read about the surgeries. You should focus your efforts on reviewing the relevant anatomy, as that is what you are most likely to be asked about. Though you should review the steps of the surgery so that you know what is going on during the case, you are unlikely to be pimped on this. Many students find de Virgilio’s textbook to be very useful when preparing for cases, and even the surgery shelf exam.

 

Practice Your Surgical Skills

 

On the first day of your rotation, you should be able to tie two-handed knots. Practice knot tying at home. It is ideal for you to start practicing before your surgery rotation. Some medical schools offer suturing workshops – take advantage of these. You should also practice one-handed ties, instrument ties, and various types of suturing, including simple suture, running suture, horizontal and vertical mattress, and subcuticular. For skin closure, you will be using subcuticular suture. Watching videos of these on YouTube and practicing at home will prepare you well. No one will expect you to be perfect, but general knowledge of how to do these is expected. Anything beyond that is impressive. In the operating room, do not be afraid to ask if you can close the skin. This shows initiative and enthusiasm, and more often than not, the answer will be yes.

 

Take Initiative and Be a Team Player

 

Everyone loves a team player, and this is especially true in surgery. As you may have heard, surgery is a team sport. Taking initiative to help the nurses, operating room staff, and residents is one of the best ways to stand out. In the operating room, help the staff move the patient, grab warm blankets, and offer a helping hand whenever you see someone struggling. On the floor, if a nurse needs help turning a patient or changing the wound dressing, help them. Offer to see any new consults that come up, and start writing their H&P, even if you do not get very far before the residents join you. Do that abdominal exam on a patient, even if it is not a patient you follow, and report back to your team. Call the nurse to ask about the urine output. Track down the outside hospital operative report on a patient who presents with surgical complications (you will be a rockstar if you can do this on a new patient before the residents even ask.) During morning rounds, write down the tasks that need to be done for all patients, not just yours, and offer the intern your help. Though you can’t put in orders, there will usually be other tasks that you can help with. Also, carry surgical supplies during rounds for wound dressing changes (gauze, Kerlix, ABDs, scissors, flushes, medipore tape, etc.)

 

Ask to Learn

 

Show enthusiasm and be excited to learn. Ask your residents to teach you how to perform small surgical tasks, such as removing drains and chest tubes, changing dressings, taking out staples, and anything else that you may be able to do as a medical student. Once you learn to do these, you will also be more helpful to your team and save them time. You should also be asking your residents and attending surgeons questions about anything that you do not know or understand, though make sure to time this well. For example, it is appropriate to ask questions during rounds, but not during a critical portion of a surgery. You can also volunteer to research a topic and give a quick presentation the next day.

 

Stay Late

 

Though you are not expected to stay late, you should consider doing so, especially when there is an educational opportunity. If there is a case that is going late, you should scrub. Often, the residents will tell you to go home if it is getting late, but asking to stay for a case reflects well on you. 

 

Start Studying for Your Surgery Shelf Exam Early

 

The NBME shelf exam is a significant factor for honoring your surgery clerkship. You should start studying for it early, as early as your first day, since you will not have a significant amount of study time with your busy surgical schedule. Make your study schedule well in advance. For surgery shelf time-saving study tips click here.

 

Though your surgery rotation will feel overwhelming, and you will often be tired, working hard will ensure that you receive honors and obtain the most from your clerkship. Surgery residents and attendings are amongst the hardest working and you will earn their respect if you do the same. Good luck and enjoy the operating room!

 

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