I wanted to put a couple of notes on the site about doing well in your general surgery clerkship for those third years who are heading that way (Mary ):
Have a good solid pair of walking shoes. Walking shoes are more supportive for standing in the OR than the running shoes. If you like to wear running shoes on the ward; keep an extra pair of walkers for wearing in the OR.
Learn to scrub properly (Mary already knows this) and don’t forget to go to the bathroom before you start a case. Even if you don’t feel like you need to go, the case will always run longer if you need to pee
I used the Third Edition of Lawrence for reading and Surgical Recall for my pocket book. I also kept the Mont Reid book in my pocket so I could read about a case quickly and answer the pimp questions. I would not buy Mont Reid and Surgical Recall. One or the other is fine.
The shelf exam for surgery is very straightfoward. If it looks like a duck and walks like a duck, it is a duck. Learn the presenting and clinical signs of : peptic ulcer disease, cholecystitis, biliary colic, mesenteric ischemia, appendicitis in both males and female, appendicitis in a pregnant female, small bowel obstruction, angiodysplasia, diverticulosis, diverticulitis, ruptured diverticulum, colon cancer, lung cancer.
Learn how to write a good op note and post op note. Do post op checks on all patients who had surgery that day if you are on call for the night. The cardinal rules of surgery: Eat when you can; sleep when you can and don’t cut into the pancreas! (unless you are Dr. Avram Cooperman)
Keep up with your reading. Force yourself to read at least 30 minutes per day and you will never be behind. Learn to properly evaluate an acute abdomen. Help the team. Check labs and replace electrolytes as needed especially magnesium and potassium. Know how to work up a post op fever.
Never, NEVER, NEVER complain to your intern or resident that you are tired. You have no idea of what tired can be until you have done a surgical internship! If you are tired, drink plenty of water, get some fresh air, walk around but don’t complain about being tired. I watched a very very nice chief resident turn into an ogre after a medical student mentioned that she was tired.
Surgery likes quick patient presentations. This is Mr or Mrs So and so on hospital day #__ or no complaints. Then go into her vitals being sure to mention her Tmax and Tcurrent and the range of BP and pulse. Give intake and output totals for the 24 hour period if you have them. Be sure to mention the NG tube output and its character (bilious) Be sure to mention each drain and the character of its output. Physical exam: mention chest and abdomen. Does the patient have bowel sounds? Is the patient passing gas? Finish up with your plan for the day.
Remove OR dressings on the post op day 2 and keep bandages and scissors and tape in your pockets to help with dressing changes. A chief resident should never be changing a dressing! If if it post op day one, peek under the dressing or note the drainage from the wound. If the dressing is off, note if the wound is closed and if there is any redness around the wound. Jump at the chance to remove staples and put in chest tubes. Jump at the chance to suture lacerations. Do not suture any eyebrows! These should be done by an experienced person. Close the incisions with staples or subcuticulars if asked. This is good practice. Practice your knots. You only need to tie a two-handed tie. Get some fishing line; a couple of non-sterile gloves and put ties on everything. Tie with gloves because you are never going to tie without them in the OR.
Make sure the patient can pee post op. The nurses are great about keeping up with this. If the patient has a foley catheter, check to make sure it is in good position and draining well.
Can the patient be advanced? Is the patient on their home meds for hypertension? Is the patient up in a chair? Can you remove the foley? If the patient has bowel sounds and is passing gas, can you advance the diet to clears? This should be in your plan for the day.
Enjoy the rotation and try to take from it, not the zebras but know when to call a surgical consultation and what to ask for. Know more about the patient than anyone except the nurse. Discuss treatment plans with the nurses. They are your friends and can really assist you in getting your patients up and out.
Surgical residents tend to be young and immature. Resist the urge to go to their level. You can have a tight group where there is lots of fun and good patient care but don’t let them push you for the fun of it. The “trial by fire” method of training surgeons and medical students is over. Surgery attendings tend to be pretty remote so most of our learning is going to come from the residents. Don’t get in the face of an attending and start peppering them with questions. You can watch your grade good out with the suction if you do this.
Have fun! This really is fun and not torture.
You will see some cool stuff and get some good hands-on experience on surgery.
Nat, thanks! You describe everything with such enthusiasm that I’ll look forward to surgery. What’s really great is that after just four weeks doing Peds inpatient, I am reading your description of what to do, how to keep up on stuff and thinking, “yup, yup, yup, I can do that.” Cool!
|QUOTE (Mary Renard @ Aug 11 2002, 04:38 PM)|
|Nat, thanks! You describe everything with such enthusiasm that I'll look forward to surgery. What's really great is that after just four weeks doing Peds inpatient, I am reading your description of what to do, how to keep up on stuff and thinking, "yup, yup, yup, I can do that." Cool! :cool:|
I am hoping that you will be the one to post that Surgery clerkship is not as evil as everyone describes. Since I am mentally deranged and doing surgery as a profession, one has to take my loves with a grain of salt.
A couple of days ago, one of my attending gleefully looked up and proclaimed that he just "loves to remove the rectum". I hope I never get that bad.
|I am hoping that you will be the one to post that Surgery clerkship is not as evil as everyone describes.|
I am having a GREAT time on surgery and will confess to being hugely, pleasantly surprised! Since I do not have any desire to pursue surgery, I kind of expected that this was going to be eight weeks that I'd have to just grit my teeth and get through. Instead I see cool stuff every day and am learning a perspective on medicine that will be good for me to remember regardless of what I practice.
Nat, you'll love yesterday's gem. We have a LOL (little old lady) on our service who doesn't actually need surgery but she was hospitalized due to concern that she might have a bowel obstruction. Her abdominal x-ray showed her to be FOS. (I'm going to let everyone figure out what that acronym means by following the rest of the story... ) Our attending gave us an impromptu lecture on how every article/book he's read, and lecture he's ever attended on the acute abdomen fails to include a common condition in the differential: constipation. And in fact it needs to be pretty high on the differential, because if the abdomen is sufficiently FOS you actually get an elevated WBC count.
And to match your attending who "loves to remove the rectum," my resident thinks inguinal hernia repairs are very cool. At first I thought he was kidding, but having gone through several of them now, I see what he means: first of all, each of 'em is different - you never know what you are going to find. Secondly, repairing all the various layers and restoring order where it had been disrupted is extremely satisfying - I enjoy watching the various layers of fascia going back together, so actually PUTTING them back together must be that much more gratifying.
So, yeah, surgery is fun!
I actually secretly hoping I don't match in emergency medicine so I can put plan B into effect…and scramble into surgery!!!
NOW yer talkin'!!!
I was seriously tempted to go surgery during & after my surgery clerkship. This was, in part, due to the preceptor I had. He’s a Philipino-trained physician, about 60, who did his internship at UW-Madison & residency somewhere in the Bronx back in the early 70s. You would believe some of his stories!!! Talk about brutal beyond belief!!!
He is now in the twilight of his career, self admission. In that light, he’s fiscally set for retirement and only continues to work cause he loves it – he does general & vascular surgery. So, he is much more selective in his cases and the load he carries – and he loves to teach & is excellent at it. this translates to not being beaten up constantly on surgery by pure volume in a fostering, teaching atmosphere. Dr Reyes had the time and desire to truly work with me, 1 on 1, and teach me things. I cannot begin to express how wonderful my surgery experience was.
From the first case on the first day, I was intimately involved in the process – not a mere high-tuition paying human retractor holder. Hell, I did all of the superficial closure for a fem-pop under his guidance - that was my first time scrubbed in! He pregressively let me do more & more. But, it was simply a ‘gift’ – I had to earn it. He had high expectations, but was such a blast to work with, it did not even seem like work doing what was necessary to meet his demands.
My last two cases on my last day were leg vein strippings for vericose veins. Dr. Reyes sat next to me and told me - “Hell, you’ve done this enough…you’re gonna do these and I’m gonna watch you”. And I did – open to close, I did both of them with only minimal intervention from him. I’ll grant you, there is virtually no surgical finesse required to do vein strippings, but it was certainly a CHARGE for a third-year medical student!!!
On a personal level, he & I hit it off! We still occasionally have lunch together. He even asked me to an elective with him. He & I are both into personal finance & investments – oddly enough, we both have eeriely similar investment styles. We spend a lot of time discussing the market. Dr. Reyes treated my like a colleague and not a mere underling…for that, I worked my ass of to live up to his expectations and was rewarded with a ton of knowledge. During my lcerkship, for about 2 weeks, there was another student on service who was more of the groveling, kiss-ass type. I quickly saw that if he/she chose to be that way, he would treat them as such…a lesson to be learned by all. to command their respect, you exect that respect AND BE WILLING TO WORK YOUR ASS OFF TO EARN THEIR RESPECT. You will find this to be true for all services you work on.
These were essentially the same as IM…every 4th day, you went on call & pulled a 36+ hour shift. You were expected to fulfill your obligations on both the day prior and the day after call – no matter how much or how little sleep you got. I did all but oneof my call shifts at St. Mary’s Med Center – the higher actuity hosp in town where all of the trauma goes. I got less than 2 hours sleep a night and over half of them shifts got ZERO sleep.
It was damned tough, but worth every minute of it! For me, surgery immediately followed IM. Surgery really propelled my confidence, knowledge and comfort-level with the concept of me as a physician. I was expected to thnk for myself, be independent and self-motivated. Dr. Reyes gave me enough lee-way that I could have slacked off and taken the easy route. Somehow knowing that I could do so motivated me to work even harder. Surgery was the only evaluation where I got a perfect score!
In the end, even though I loved surgery…it also taught me that I was not destined to be a surgeon. I know I have the skill and capacity to be a surgeon and likely a good one. However, my clerkship offered me the chance to experience the “life style” and I value my personal life too much. were I a single man…maybe. However, I made a promise to myself and my children to be a looooong time ago that I would not be a father-in-absence. I know myselkf well enough to know that I would be very apt to marry my career – to succeed as a surgeon, or any other type of physician, does not equal success as a father. So, as in all other life-issues, we must learn to balance our obligations.
Of course, now that I know that I love anesthesia 10x more than surgery (my #3 career choice behind ER) AND that anesthesia affords me the luxury of fulfilling my promise to be an involved father…there is no doubt where I need to go!!
A gas-passing we will go!!!
If you have encountered this, being at the bottom of the foodchain, how do you deal with surgeons (attending) that are just truly aholes in your clerkship or in residency? As a scrub tech in surgery, surgeons of this sort seemed to be the norm. Just as well, there were a many good decent surgeons who were well-mannered.
Being a male, and one not to shy away from unwarranted provocation, I wonder if I will be able to keep my cool in the presence of someone who made it their sole purpose in life to offend and demean those climbing their way up the pole. Is it never appropriate to threaten to put your foot up an attendings a if provoked, when in a clerkship or residency (this is one of the reasons why I will fear surgery rotations, for fear of doing something that I probably shouldn't do)?
|QUOTE (jpatter916 @ Oct 23 2002, 05:36 PM)|
|If you have encountered this, being at the bottom of the foodchain, how do you deal with surgeons (attending) that are just truly a**holes in your clerkship or in residency? As a scrub tech in surgery, surgeons of this sort seemed to be the norm. Just as well, there were a many good decent surgeons who were well-mannered.|
Being a male, and one not to shy away from unwarranted provocation, I wonder if I will be able to keep my cool in the presence of someone who made it their sole purpose in life to offend and demean those climbing their way up the pole. Is it never appropriate to threaten to put your foot up an attendings a** if provoked, when in a clerkship or residency (this is one of the reasons why I will fear surgery rotations, for fear of doing something that I probably shouldn't do)?
I have had exactly the opposite experience. I find that the "jerks" in my chosen specialty are few and far between. Here at UVa, I haven't found an attending who was anything less than a total blast to work with. All of my attendings have been patient and great teachers. I had the same experiences at Howard, my alma mater for medical school. I had attendings who asked nurses to be extra polite to the medical students because we were just learning and needed guidance instead of derision. At Mayo Clinic, my attending physician, a world-renowned endocrine surgeon was one of the nicest attendings that I have every encountered. I just haven't found a bad apple yet and I am around the folks every day.
If you read some of the posts by GED2MD, I think you will have to agree that this person is one of the nicest and most helpful folks on the newsgroup. Again, GED2MD is a surgeon.
Keep an open mind when it comes to your surgery clerkship. It can be an extraordinary learning experience if you let yourself take knowledge away from it.
I try every day, not to be a jerk no matter how much goes wrong. I just love to break a stereotype whenever I get the chance and I am a very good surgical resident. I try to teach my students and help my patients. I was voted Employee of the Month by the nurses on the vascular surgery floor because I try to go out of my way to get the best for the patients.
I also think that your perspective will change once you take on the role of medical student. Good luck!
|QUOTE (njbmd @ Oct 23 2002, 09:23 PM)|
|If you read some of the posts by GED2MD, I think you will have to agree that this person is one of the nicest and most helpful folks on the newsgroup. Again, GED2MD is a surgeon. |
*grinning ear to ear*
Jack, if you survived being a scrub tech, then you've definately seen the worst of a surgeon's behavior. Working in the OR can make a person, shall we say, grumpy?
I'm sure you've worked on your car before, haven't you? You know how, when that bolt is stuck, and you're struggling, and your back hurts, and the light is no good, and..... god forbid one of your kids walk over at that moment and try to ask you something. That's the way it feels sometimes in the OR, and people often become far more irritable than they normally allow themselves to be.
I suspect that you will encounter unecessarily rude and arrogant people, probably more on surgery than on other rotations, unfortunately. And being that you are both older and have worked in surgery before, it will be hard for you to take 'correction' from a pimple faced kid who's never held a scalpel. Dave (OldManDave) has written some great posts about improvising this wide-eyed look of epiphany in order to satisfy the ego of a helpful pedagog and help him to move onto other things.
Nat is like the perfect sister ("you never yell at HER!"). She's great....could you be mean to her? She's smart and socially savvy and has probably expertly handled any potential conflict so quickly and smoothly that, when everyone walked away, no one realized there had been a problem. I, on the other hand, am a hothead. Let me tell you firsthand, this is not the way to go in medicine. All of the detriment will fall on you, none on your antogonists. You have everything to lose - learning opportunities, people's trust and goodwill, your reputation - and nothing to gain when you offer resistence to higher ups. Be humble, my man, be humble. Fake it if you have to.
|Being a male, and one not to shy away from unwarranted provocation, I wonder if I will be able to keep my cool in the presence of someone who made it their sole purpose in life to offend and demean those climbing their way up the pole. Is it never appropriate to threaten to put your foot up an attendings a** if provoked, when in a clerkship or residency (this is one of the reasons why I will fear surgery rotations, for fear of doing something that I probably shouldn’t do)?|
let me just add that the stereotypic surgeon’s attitudes (of which our member surgeons are the antithesis ) are not unique to surgeons -
I’ve encountered them all over the business world - some are up front about it, some behind your back about it - but you can’t go around blowing-up at them at work … so you find other ways to cope and get your work done. I’m sure you’ll find other ways as well
It's nice to know first hand the appropriate way in handling difficult or frustrating situations. Thanks for the insight. And, please, my apologies if I have offended anyone in asserting such a generalized perception of surgeons/attendings. Thanks all.
I wanted to add a note or two about surgeons and frustration: Most of the third-year surgery folks have encountered a little book called Surgical Recall. There is a little chapter in there detailing the art of “camera driving” during laparascopic procedures. In that chapter, there is a recommendation that you bring your, iron underwear" into the OR with you because you are going to get yelled at. The whole Recall series was written by faculty and students at UVa. In fact, the new edition of BRS Surgery was written by a UVa alum named Traves Crabtree. Many of the current residents and faculty have edited or contributed to both very popular books.
I had the experience of driving for my residency director. He was on his third case, a laparoscopic gastric bypass and things were not going well. The camera kept fogging up and I was slow to the FRED because I was largely plastered against my chief and reaching around him as they worked. My residency director and chief started to snarl and swear but I kept challenging myself to work through their conversations and anticipate their next move. They got the case done but it took longer because of the camera work.
Later that night, my residency director made an attempt to apologize to me. I stopped him only to say that one, I have heard worse language, two, I am a big girl and three, I enjoyed the challenge of making my work better. I learned how to function better under the stress and I learned how to adapt to a difficult situation. In every challenge, there is learning. You have to be able to not take anyones comments to heart and keep moving to where you want to be. The only person who can make you feel like a loser is yourself. If you allow others to treat you like the bottom of the foodchain, you will find that you will become the bottom of the food chain.
My attending in this case is also my residency director and the ultimate determiner of my ride here at UVa. While I always want to be on point in his presence, I really do not allow him to treat me any differently from any other surgeon that I have had the good fortune to work with. If a person feels obligated to make derogatory comments about others on a regular basis, even if that person is a Nobel prize winner in medicine, it speaks volumes about their insecurities and not about the object of their derision.
Am I offended when people generalize that all surgeons are bastards? Not in in the least. Some of us are bastards at one time or another. I just try not keep the string going.
P.S. I now think of that camera as the ultimate joystick. I am flying Stealth missions over Iraq. Here I go for another bomb drop! Weeeeeee!