Applying to surgery, but freaking out about starting surgery Sub-i and away rotations!

[Iris42]

After my surgery clerkship, I've realized that it's a lot harder to shine as a med student in surgery compared to medicine clerkship because in our hospital:

1-There isn't much attending interaction, we mostly see the residents
2-Rounding is only on post-op patients with pretty straightforward management.
3-There is minimal clinic time.
4-We spend most of he time in the OR, where there is only minimal pimping.
5-During the cases they are mostly walking the intern through the steps, there isn't much room for me to ask questions without interrupting.

I am applying to surgery, but I'm worried about my performance as a Sub-i or on away rotations. I have good suturing skills and know the answers to the pimping questions when asked. How am I supposed to impress these people?!

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[psychapp121]

You impress by rounding on a lot of patients, knowing your patients well, doing whatever the residents say and trying to make their lives easier, having a good attitude, being friends with everyone and having good personality, and having good knowledge/OR skills

 

[mistafab]

You have the wrong idea. Everything you listed is how you excel.

Stay calm, take a deep breath - you got this.

 

[operaman]

A few thoughts:

1) residents an attendings talk. At our program faculty ask us for a list of visiting students divided into tiers ranging from “yes bring this person to an interview we would love to have them as a colleague” to “we don’t ever ever want to see this human ever ever again.” Most end up in a middle “did fine, let the rest of their app decide interview status” category. But they’ve always respected our top and bottom tiers.

2) anticipate. Follow every patient, make the list, make checkboxes just like the intern. Follow things up. Run thing through the intern or junior on your service so you help them shine. I remember the best sub I ever would also follow the consult board like a hawk and within a couple minutes of me as the pgy2 getting a consult she was texting me asking if she could see it with me and that she had already gathered the necessary tools/scopes/etc. Made my job incredibly easier and impressed everyone. She anticipated work and got it done. There’s a big difference between the usual “can I help with anything” and “i see we still need to do X and Y; mind if I knock those out while you’re doing Z?”

3) prepare well for the OR. I already know most of the cases scheduled for the next month, so students should be able to read ahead by a few days. You can also look for cases where your assistance would be helpful. If you’re not sure what these are, ask your residents. Really read up on the cases so you can retract well. Students always malign retracting but there’s an art to it and it hinges on you knowing the case and the next move.

4) take call. This is usually where students get a chance to shine because you get the overnight Battlefield promotion of sorts When most people above you are gone. Be proactive and quietly helpful. This may also be when the skills you’ve been practicing pay off as you may be asked to help sew or assist on other procedures.

5) be engaged at all times but don’t be annoying about it. Less asking how to help and more looking around and figuring out how to help. Carry supplies or pre set them in rooms before rounds. Pre round and get Overnight nursing info so the team doesn’t have to find them (the one you want is always missing). Put on gloves every time you walk in a room so you’re prepared to help. Have a light ready so the Chief never even has to ask; you’re just quietly there with yours already on and helping before they even have time to ask. You’ve got a spare set of gloves for the Chief just in case. All these things are helpful and require no talking so impossible to be annoying doing them. Obviously we want you to talk and be part of the team too but I know it’s easy to cross the annoying line as an eager student, so the more helpful things that can be done quietly the better.

6) clinic time is important too. This is where you will get a chance to present and make impressions on attendings. Prepare for these like the OR, especially on new patients as they often have extensive outside records for review. For all cancers, Attempt to stage them based on the data you have and present it that way. Every student says “this is a 64 year old man with colon cancer” but the good ones say “this is a 64 year old man with a new diagnosis of T2N1 adenocarcinoma of the.... Based on the NCCN guidelines additional workup would include X and Y and Initial management would be surgical resection and lymph node dissection.” You can also make an effort to assist in documentation. Learn their templates and write notes unless they say not to.

I guess a key point for a sub i is that it’s now less about your learning and more about your ability to help get things done. In surgery this often requires skills and time is limited so efficiency is prized. Presentations if they happen really need to be brief. You should know enough to give a full classic presentation but may only say one or two sentences. Know more; say less - that’s your motto. Much of what you do is to support the intern and junior and trust that Other people notice (we do) and that the juniors will relay their thoughts about you to everyone else (they will).

 

[OnePunchBiopsy]

First off, you got this! Cool to meet someone else who appreciates surgery.

Universal rule of surgical aways: Always try and rotate on the service headed by the PD of Chair.

1-There isn't much attending interaction, we mostly see the residents

I found the best time to interact with attendings was in clinic presenting patients. Also if clinic hits a slow point (patient doesn't show, etc.) thats a good time to ask questions, chat.

Like others said above, residents and attendings talk a lot. I always tell attendings when a medical student impresses me (or the opposite in extreme cases).

2-Rounding is only on post-op patients with pretty straightforward management.

Always try and give an oral presentation when you can. Speak confidently. Even if management is straight forward, let them feel like you know your stuff and therefore would make a great resident.

3-There is minimal clinic time.

One or two times in clinic is all it takes to leave an impression. If you get no clinic time, try and present on rounds or go see and present ER consults.

4-We spend most of he time in the OR, where there is only minimal pimping.

Pick a convenient time and ask questions during the operation. Try and avoid asking questions you already know the answer to (we can pick up on that sometimes and it is generally viewed as annoying).

If you see that a resident is holding two retractors, if the time is right, offer to retract to free up more hands.

5-During the cases they are mostly walking the intern through the steps, there isn't much room for me to ask questions without interrupting.

With this advice above in mind, remember that reading the tone of the OR is a keen and valuable skill. If you feel it is a bad time to ask/lend a hand, avoid doing so.

We've had great students rotate with us who only spoke when spoken to in the OR, and they always left an (overall) positive impression on the residents and attendings. Being viewed as "too chatty" is far worse.

 

[Tozanzibarbymotorcar]

Really read up on the cases so you can retract well. Students always malign retracting but there’s an art to it and it hinges on you knowing the case and the next move.

Can you please comment further on these retraction skills? I didn’t know there was an art to retraction.

 

[FindersFee5]

Can you please comment further on these retraction skills? I didn’t know there was an art to retraction.

Just a medical student coming off my surgery rotation, but here's my take on it. Retraction is essentially about anticipation. It's your way of showing that you know what is supposed to happen next in the surgery. I think the easiest way to think about it is by asking yourself, "If I was performing this surgery, what would I need to do next, and what exposure do I require to do that?"

If you're ever in a case with a few residents and you aren't doing anything, instead of watching the main action, watch what the second assist is doing sometimes. They move without being asked for the most part and they aren't dumb robots who hold the retractor when the attending hands it to them until they're told to release. Try to emulate that.

With that being said, there are attendings that prefer you to ONLY do what they ask. For those, there isn't as much you can showcase. Just do what you're told and make note of it for next time you work with them.

 

[operaman]

Can you please comment further on these retraction skills? I didn’t know there was an art to retraction.

The poster above pretty much nailed it. If you know the steps and the anatomy you can use your retraction to show the operating surgeon what they need to see. Just watch someone more senior retracting and assisting someone more junior and you’ll see what expert level retraction looks like. As a resident you’ll get a false sense of skill thanks to your attendings retracting for you, and then you’ll get the classic awakening as a more senior resident when you’re the one taking a junior through something and suddenly it’s a lot harder than it was a few weeks earlier. The retraction is critical to good exposure which is a fundamental principle of any successful operation.

As a student you have to be a little careful because people don’t know and trust you yet and may not appreciate too much independent action. It is possible to hurt someone with a poorly placed retractor. Even then, if you’re paying attention and see the resident struggling and working in a hole, it’s easy to say “would it help if I got a retractor in there and helped open that up a little?” I’ve had students do that and it’s usually met with a “yeah, grab an army navy...”

Basically as a sub I you want to begin making the transition from observer to assistant. If your hands are empty, you aren’t helping. Sometimes there’s really nothing you can do, but pay attention and look for times you can lend a hand. Even if they decline your offer to retract something, you’ll come across as someone who is more engaged and thoughtful.

 

[WedgeDawg]

@operaman gives some excellent advice. Do that or even try to do as much of that as possible and you’ll be in a position to be a strong sub-I.

Depending on which surgical field you’re in, sub-Is may be one of the most important parts of your app. If you follow the above advice, you’ll be in good shape.