How to Crush your Surgical Rotations

So you think you can surgerize? Well this guide contains the essential tips needed to succeed on any surgical rotation whether it be general surgery, plastic surgery, or ophthalmology. As you already may know, if you want to match into a competitive surgical specialty it is essential to honor your surgical rotations. Suffice to say, it would not be a good look to just pass surgery after you just honored internal medicine (since you read our blog on that (link)). This guide contains the most relevant information needed to succeed in your surgical clerkships.

Let’s first cover the General Surgery Shelf exam. The most useful resources are listed below.

Resources:

1. Pestana’s Surgery Notes
2. DeVirgilio’s Surgery
3. OnlineMedEd Notes
4. UWorld STEP 2 CK General Surgery Questions
5. 4 Previous NBME Exams

Pestana’s Surgery Notes is a light read. It should be read multiple times over the course of the 6-10 weeks that you will be on your surgery clerkship. Ideally, it is best kept handy in your whitecoat pocket so it can be read in between cases and when you have downtime in the hospital. DeVirgilio’s is precisely the opposite. That book is so thick you’ll herniate a disk if you aren’t careful. However, the layout is simple and it is easy to read. The questions at the end are also great for preparation right before the shelf exam. One pass through the entirety of DeVirgilio’s provides a solid foundation. To round out the reading resources, OnlineMedEd has printable notes. These are quite lacking in terms of detail and background so they are best read as refreshers/for repetition. There are also about 300-400 general surgery questions as part of the UWorld STEP 2 CK subscription. Focus on the answer explanations and management algorithms for abdominal/respiratory trauma. Know how to handle volume resuscitation for trauma and burns as well. Lastly, the previous NBME exams are a great resource to test yourself and see what the real thing will be like. If you want to work up a nice sweat, do these under timed conditions.

Now that we have the studying part out of the way. Let’s get to the fun part.

As always, having the right mindset is key to accomplishing your goals. If you haven’t yet read our Internal Medicine guide go ahead and do so. Proper frame of mind is covered there. Similarly, how to handle interactions with attendings, residents, nurses, PAs, patients, and fellow students is also covered in that guide (Link). These skills are actually even more important on surgical rotations as the stakes can be much higher due to a potentially malignant culture and higher stress situations. There will be times when the attending surgeon will yell at you or strongly criticize you. Resist the reflexive urge to soil your scrubs and start crying. It is during those times that your mindset and willpower will be tested. Think of it in the sense that the residents/surgeons are trying to test whether you have the mental stamina to survive alongside them. Get used to mastering this skill as it will come in handy throughout your residency training as well.

Another important topic to cover is Operating Room etiquette. Many students have changed their minds about pursuing surgery after messing up in the OR. First of all, avoid fainting at all costs. Seems simple enough, but every year there is always one student who falls victim to his/her autonomic nervous system. Don’t let this be you. Take preventative measures- make sure you eat a light snack before going into lengthy cases and stay well hydrated.

Moreover, make sure to make all pre-game adjustments prior to scrubbing in which include adjusting your face mask, making sure the surgical cap isn’t too tight, removing watches/jewelry, and having the proper fitting surgical gown/gloves ready in the room.

The play-by-play breakdown is below. It is best to give yourself at least 30 minutes to an hour prior to surgery start time to follow through all the steps.

1. Find out which operating room the surgery will be taking place in by looking at the OR board.
2. Go to said operating room well before the case starts. Familiarize yourself to your surroundings. Where is the operating table in relation to the sterile instruments? Where are the monitors/lights above you (so you don’t contaminate yourself in surgery)? What side of the patient is the operation taking place on (so you know where to stand)?
3. Write your name on the white board along with the year of medical school that you are in and your glove/gown size. This is for the scrub tech to know what size gloves and gown to get for you and the nurse to input into the computer.
4. Introduce yourself to all the personnel who will be in the room. This includes the attending, resident, scrub tech, PA, nurse, circulator, and patient. I cannot emphasize how important this step is.
5. Do a morning pre-scrub if you have not already done so. If you do not know how to wash your hands for surgery there are plenty of tutorials on YouTube. Make sure you know how to do this and maintain sterility throughout the procedure.
6. When the surgeon is doing the time-out at the start of the case do not speak and do not move. This is an easy way to get yelled at.
7. Once the case starts, do not do anything you have not been asked to do. The exception to this is if you have already worked with this surgeon/resident and the rules of what you are allowed to do have been established. Do not touch anything without being told to. Bottom line is do only as much as you are told/given permission to do. Do not think that by doing more you will earn brownie points. In fact, the opposite will actually happen. You will most likely screw something up or do it in a manner of which they did not want. Trust me.
8. Do not touch/grab anything off the sterile mayo stand unless told specifically.
9. DO NOT CONTAMINATE anything. This is easier said than done. It will take some time in the operating room environment to understand exactly how to execute this so don’t beat yourself up if you contaminate something. Just be sure that whatever you contaminate is easily replaceable like your gloves, light handle, or one instrument. Basically, just don’t contaminate the surgeon or even worse the operating field.
10. Once the case is over and the surgeon/resident scrubs out, your work is not done yet. Remain in the room to assist in clean up and transferring the patient back over to their normal bed. Use the board in the room to help you with this. Make sure you had your pre-workout for moving larger patients.
11. Finally, help transport the patient in their bed back to PACU.

The steps listed above are the bare-minimum to making a good impression. In order to make a great impression, suture skills, knot-tying skills, and medical knowledge are requisite.

Suturing is an essential skill to have to be a great medical student on surgery and impress. The best way to get good at suturing is to practice. There are countless YouTube videos on this topic as well. I recommend knowing how to do simple interrupted, simple running, figure-of-8, half-buried, buried, subcuticular, horizontal mattress, and vertical mattress. Get yourself a suturing pad from Amazon which creates less of a mess than suturing a banana or chicken leg. As per obtaining scissors, forceps, and needle-driver it is best to ask your school’s surgery club, a resident, or one of the scrub techs you are close with. Amazon is also always an option. After obtaining supplies, make sure to keep practicing. The times you get to suture at the end of a case is your time to shine.

Knot tying can also be learned using YouTube. Be sure to learn one-handed and two-handed knots and be able to do them in both left and right hands. Dental floss is a great option to improve hand dexterity. For an added level of difficulty, wear gloves.

Lastly, to become an all-rounded surgeon having a wealth of medical knowledge is key. As a medical student, be sure to find out which cases you will be a part of for the next day. To do this, ask your resident or check the OR schedule. Then, the night before, be sure to read up on the cases. Google the case, watch videos showing the surgical procedure, know the relevant anatomy cold, and if implants are being used you may want to look up the surgical technique for that. The shelf preparation outlined earlier should help with building up a knowledge base as well.

Lastly, be sure to have fun. Surgery can often be a brutal clerkship especially if you are trying to match into a surgical specialty. Be sure to enjoy the time and not take yourself too seriously. Know your role, work hard, and have fun. DaVinci will continue to release blogs with advice for students and other inspiring stories. Please message us directly at [email protected] with any topics you would like to see covered.

About the author of this blog: Ronit Shah, M.D. is an Orthopaedic Surgery Resident at Temple University in Philadelphia, PA. Dr. Shah is also a co-author of the Principles of Clinical Biochemistry Textbook from DaVinci Academy.