Surgery Guide for Students

 

How to Survive your Surgical Clerkship at the University of Washington, by a former surgical clerk.

How to study
How to round
How to operate
How to be on call

Part I. How to study

Buy or borrow a copy of Blackbourne "Surgical Recall" (Williams & Wilkins). Carry that one in your pocket and use its Q/A format to quiz yourself before going to the OR on a case. During "downtime" on the wards, try to get through most of that book.

Buy or borrow either one of these: Greenfield "Essentials of Surgery" (Lippincott Raven) or Way "Current Surgical Diagnosis and Treatment" (McGraw-Hill). Carry this one in your backpack for a reference. Read it on the bus. Use it at home to study high-yield topics in more detail than Recall will have.

Take that folder they gave you and find the "Lecture Topics" section. These are the high-yield topics. These topics cover the essential problems in surgery. If you know a decent amount about each of these, you'll know as much as you need to. Here's what to do:

Get a stack of index cards or a pocket-sized spiral notebook.
Each lecture topic is one card or page.
For each topic, write a few sentences for the following:

1. Epidemiology -- who gets it, risk factors
2. Pathophysiology -- how does this disease work
3. Presentation -- signs/symptoms
4. Workup -- what are found on H&P, labs, imaging
5. Treatment Options -- indications for/against surgery, what kind of operation
6. Complications -- risks of surgery or risks of not operating
7. Outcomes -- recurrence, percent cured by operation

See an example.

Take the cards or notebook to the lectures and fill in the sections while the lecturer talks. At the end, when they ask if there are any questions, you just look and see which section is empty and say "Could you say a few words about the ... epidemiology of this process?"

Fill out the topics not lectured on from the Essentials or Current book. By the end of the course, you've got your super-compact master knowledgebase for surgery. Don't lose it.

Part II. How to round

These tricks will help you:

1. Become a Master of All Knowledge
2. Become a Powerful Weapon of Good
3. Become a Saint

1. Become a Master of All Knowledge: You start by knowing which patients are "yours." Typically these will be any straightforward patients you helped operate on. Otherwise, volunteer to pick up patients so that you always have at least two. Always make sure you know exactly which patients are your responsibility. Do these things for each of your own patients:

  • Use some kind of patient tracking system and keep it up to date. A Master of All Knowledge can provide ANY piece of information, no matter how trivial, at ANY time or place. (I kept my cards in the back pocket of my scrubs, so I always had them).
  • Keep track of tests and procedures scheduled for your patient and seek out the results. Consultants, radiology, and the OR won't call you, they'll call a resident -- A Master doesn't wait for knowledge to come, A Master goes and gets it.
  • Spend some time practicing your presentations so that they are short and useful. Sometimes writing your progress note as a script works pretty good:
    • Name, Age, Sex, Post-op day number what from what operation.
    • What happened overnight and how does the patient feel? -- One sentence here, don't ramble.
    • Vital signs, Ins/Outs, Focused exam, Labs -- This is just the facts, no speculation or interpretation.
    • Assessment -- Here's the meat. Organize it to address findings and 'sum up' the picture, outline the n problems.
    • Plan -- Same organization as assessment with a plan for each problem.

See a patient tracking card (coming soon)
See a presentation on rounds (coming soon)

2. Become a Powerful Weapon of Good: You are the one whose pager has not yet become an infuriating, work-stopping, poisonous talisman of torture. You have the opportunity to help the team finish their work earlier, cure their patients faster and get home to see their families sooner. The more you help them do that, the more love, teaching, and opportunity they will pile on you. Here's how:

The basic principles are: Pay Attention; Understand the Objectives; Do What's Needed Without Waiting to be Asked.

Carry any needed item in your pockets on rounds: Scissors, tape, 4x4s, flashlights, stethoscopes. The less often someone has to stop rounds to go get some item, the faster things will go and the more effective you are as a Weapon of Good.

Pay attention to the workflow and anticipate. If a patient gets their wet-to-dry dressing changed every morning on rounds, make sure there's dressing supplies and a bottle of Normal Saline at the bedside. If the team rounds with a rounding cart and charts, have it set up and ready when the team arrives. Keep a stock of forms handy so TPN, radiology and other things can be ordered on the spot and it's done with. Offer to write orders or fill out forms while someone else presents their patients.

The ultimate secret: find the social workers and charge nurses tell them everything you know about your patients and see if there are special discharge needs, like home O2, nursing home placement, home TPN, follow-up appointments. Volunteer to your team to get started on that stuff. There is no more Powerful Weapon of Good than the one who leapt tall barriers to discharge at a single bound.

3. Become a Saint: This simply means to let your unwavering principles of compassion, service and honesty guide your attitude and your interactions with patients and families. On busy surgical services, you may be the one member of the team that the patient and family sees most. Remember: you make the impression for the entire team and for surgeons in general.

  • Be nice -- when you move a bedside table to do your exam, move it back when you're done.
  • Be honest -- if they ask you a question you feel you ought to know, but don't, tell them, "That's a good question to put to the team, I'll make sure you get an answer today." Don't try to bluff your way through with educated guesses.
  • Be compassionate -- when a patient reports bad news or says they feel awful, don't blow past it to your abdominal exam; stop briefly and commiserate with a simple "I'm sorry things aren't going as you hoped, but we're all here with you and working hard to help you through this. I'll be back with the team later and then we'll see if there's anything else we can do to help."
  • Be professional -- A great surgeon once said, "There is no true deterrent to the incorporation of professionalism into my daily practice. It is something I signed on for long ago, and it began in my soul."

Part III. How to operate

Get as much advance notice as you can about cases. Ask your senior residents what cases they think you should scrub on or whose operations you should go to for the coming week. Read up.

Three things you must take with you into the OR:

1. Empty bladder
2. Full stomach
3. Clear conscience

1. Empty bladder: Learn the closest bathroom to the scrub sinks; before you start to scrub, check: bathroom? eye protection? mask on? rings off? gloves/gown given to scrub nurse?

2. Full stomach: Keep a snack bar in your white coat at all times for emergencies. Power bars are made of sawdust and make you feel nice and full. Mmmmm...

3. Clear conscience: To have a clear conscience going into the OR, you must: know the patient; know what operation is about to happen and why; know the anatomy where you'll be operating; know the pathophysiology at the root of it all (they won't have you demonstrate a stick-tie, but if you're helping remove a parathyroid gland you'd better know what its hormone does).

Introduce yourself to circulator and scrub nurses. Learn their names. Write yours on the board with your glove size and give your gloves to the scrub nurse. Help set up if you can. They'll teach you stuff, like putting in Foley catheters.

Part IV. How to be on call

Coming soon.