Friday, May 16, 2014

What do students do on third-year surgery rotations?



A woman who has been accepted by a few medical schools and is trying to decide which one to choose asks

What extent of involvement should be expected for medical school surgery rotations? I have enjoyed shadowing general surgery and feel that a field involving some procedure may end up being my fit, or at the very least something to enjoy in medical school. I am curious as to the type of participation in procedures (suturing/closing for example) that is typically allowed as a student versus that allowed and expected as a resident. 

In most third-year surgery rotations, students can do some suturing of skin and maybe lacerations in the ED provided the student has practiced knot-tying and using instruments outside of the OR. Opportunities to suture in the OR are fewer these days because of skin stapling and the use of glue, which are both faster than suturing. Hardworking and interested students are far more likely to be rewarded with things to do by residents.

Otherwise, there's a lot of camera holding for laparoscopic cases and retracting for open cases. Students used to do H&Ps and write postop orders but the electronic medical record has curtailed those activities greatly.

Medical school has changed a lot over the years. As a fourth-year student in the early 1970s, I placed many subclavian central venous catheters—some of which were unsupervised. Six years ago, I was about to let an intern place a subcutaneous chemotherapy port in the OR. It was halfway through the academic year. I asked her how many subclavian catheterizations she had done. She said she hadn't done any but had seen one.

I can't say whether that lack of experience is common to most current med students, but I think it may be.

Of course, residents get to do much more as they progress through the years. Residents in community hospital programs tend to do more cases during their first 2 years and often will have performed more cases over the 5-year course of residency training than those in pure university based programs. Of course, there are exceptions.

If this is really a major factor in your decision-making process, I suggest you try to talk to some students at the schools that you have been accepted by and see what they have been able to do during their third-year surgery rotations.

You will probably find that students who do third-year clerkships at community hospitals affiliated with med schools get to do more hands-on work too.

The same goes for those applying to residency. If you really want to know what goes on, talk to some of the residents who weren't chosen to meet the applicants on interview day.

I hope some of our readers will comment.

20 comments:

  1. I'd echo the suggestion to ask students at the school who have been through their general surgery rotation. Even at my school, it varied greatly depending on which hospital and which service you rotated on.

    I elected to do a rotation at a community hospital. During the day, I carried the consult pager, and did the initial H&Ps before calling the resident. If it was an ED consult, after calling resident, I would suture the laceration or do the I&D with the resident's guidance. If that patient went to OR, I was there. It was a great experience. Others who rotated at the flagship center did not have that independent learning.

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  2. RE: experience of med students and residents today...You and I are about the same "age", so to speak. A while back I was trying to read a heart failure chest X-Ray with a resident in May of her second year. She was totally lost regarding landmarks and findings, having NEVER looked at an actual image up until that point but relied solely upon the radiology reports.
    I was GOBSMACKED. Hey, I understand the practice of is changing by leaps and bounds, but some "basic" skills should be included as part and parcel of the learning experience.
    Or am I a dinosaur?

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    1. The practice of just looking at reports is unfortunately common. It's a bad habit to get into and if you don't look at films when you are a resident, you won't when you're an attending either.

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  3. What Anon said above I can echo from the patient side. I, a non MD, have read enough that I have an internist say 'she's actually understanding this' and can read bloodwork better than most specialists.

    Including medical research ...

    Very scary ...

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  4. I wonder if med students and residents coming out of countries like South Africa with a vast overabundance of patients will come out with far better training than comparable Americans given the amount of experience they will be afforded.

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    1. I don't know, but I think residents in South Africa both see more patients and do more cases than those here in the states.

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  5. Without giving too many identifying details away, my school is associated with a large county hospital and third year medical students routinely assist with multiple tasks per the service they are rotating on. Suturing lacs in the ED, driving the camera and holding traction is probably the minimum expected of every student. There were several opportunities to gain some surgical skills. Administrative/paperwork was part of the clerkship. My experience as a student was:

    -4 weeks on an elective surgical service - 5-6 patients per student, notes and orders entered daily and cosigned by resident and attending. 2-3 cases daily, routinely closed, sometimes opened, got to practice stick ties and stitches. Put in several central lines supervised by R3. Good variety of cases, comparatively long hours.

    -4 weeks on acute care service - overnight call q3 days, routinely had >25-30 patients on service, students expected to be in the OR and participate. Low level cases (lipoma excision, I&D) did by self several times with R3 poking head in the OR once or twice. Assisted on gallbladders and appys throughout the night. Triaged all consults from the ED, updated "the list" of patients for all services. Multiple central lines placed, intubations, misc. procedures. Trauma call concurrently. Frankly a malignant service. The adminstrative stuff was by far the least interesting but gave me some versatility.

    Haven spoken with multiple students from other schools, my experience was probably not typical.

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  6. to sum up - students were expected at minimum to formulate an articulate a coherent plan for the patients they were seeing. this included ordering and interpretation of studies, knowledge of surgical vs nonsurgical interventions, etc. lots of prodding to learn independently, not much teaching/mentoring.

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    1. You said the magic words "large county hospital." Usually hands-on opportunities are more abundant at public hospitals. Your experience sounds good. I agree it is not typical of other students' rotations.

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  7. I agree with Skeptical Scalpel's blog entirely. I think, perhaps, one of the "skills" a 3rd-year resident should acquire is how to dictate a report ACCURATELY and COMPLETELY. I was blown away, when, as a 3rd-year surgical resident, I came across the dictated OPEN cholecystectomy report done by one of my attendings (some 10 years prior) that was 3 sentences long. No...not 3 run-on sentences long...but 3 sentences. It was abysmal.

    I understand this is not typical. But there is an art to dictating an anatomically accurate and complete report of an operative procedure. It is as important as an H & P.

    Also, I'm not surprised the 2nd year medical student referenced above couldn't understand what they were looking at on a CXR. That student just spent two years learning about Golgi bodies, mitochondrial DNA, Kallerman's syndrome, the intricacies of the Kreb's cycle. . .all taught by non-clinical PhD faculty. But that's been covered in another blog, here, on SS site.

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    1. I agree that dictation is usually not taught during residency. I have written about that. Here are two links: http://skepticalscalpel.blogspot.com/2011/11/dictations-can-be-tricky.html and http://skepticalscalpel.blogspot.com/2012/06/dictations-can-be-tricky-part-2.html

      That was a second-year resident who couldn't read a chest x-ray in the second anonymous comment on this post. It doesn't matter that much because I agree with your comment anyway.

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  8. Lots of retracting, opportunities for suturing/closing. Possible office opportunities to I and D depending on patient population. Less procedures, more listening and observing. I've learned how to use the camera as well.

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    1. I hope you have found that the secret to good camera holding is not to move it quickly. If you pan slowly, everyone is happy.

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  9. I've been told that as a med student, I should try to rotate only at my academic center, as letters from the academic surgeons are the important ones for residency. Is this the case? Would having LORs from the community programs (which I would prefer to rotate in) be less beneficial than those from the academic center (especially if I hope to match in a community program and practice rurally)?

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    1. Nic, that is a really good question, and there is no clear answer. Is a letter from a famous academic surgeon who barely knows you better than a letter from a good community hospital surgeon who worked closely with you? I think that some program directors favor one way and some favor the other. I could usually tell by the tone of the letter that a department chair really didn't know a student. I can't speak for all PDs though.

      I'm not sure what advice to give you. I'll tweet your question to my followers and see what they think.

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  10. I do agree that over the years, more junior trainees have been afforded less and less responsibility and hands-on experience. I also agree that you will probably get more hand-on experience at a community hospital rather than at an academic center, simply because there will be more bread-and-butter cases that are appropriate for teaching and learning at a junior level.

    Having said all this, however, it's different EVERYWHERE, and you'll generally do better if you go in with the goals of 1) Helping the team and patient as much as possible and 2) Learning as much as possible. The more active and interested you are (but not in a pushy, know-it-all way), the more the members of the team (from intern up to the attending) will let you participate. Look up the cases for the next day, know the ins and outs of all the patients. Help the intern with the discharge summary. Call down to the lab to figure out why that creatinine is taking so long to come up. Anything you can help to streamline the day will be greatly appreciated, and will earn you respect and trust. I find that too many medical students want to know what residents and attendings can do for them...like what we can do for their "leaning experience." This sometimes grates on the team, because even though we want to teach and show you things, we first want to know if you can take responsibility for yourself and contribute without expecting anything in return. Give a lot and you'll be rewarded.

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  11. Hope, thanks for reinforcing my comment about getting more to do at a community hospital.

    Your second paragraph is excellent advice for students on any rotation.

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  12. We might as well start tracking these matters on the internet.
    Www.SemmelweisSociety3.net

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  13. You didn't share an important detail. After you found out this was the intern's first subclavian line, did you take the procedure back or did you teach her?

    We aren't giving the responsibilities to students and residents that give them the learning opportunities they need. Whether it is a function of the culture of safety, or volumes, or changes in technology and/or cultural practice (BiPAP and POLST forms have cheated many a resident out of a tube that should have been theirs), the reality is that we are failing our learners, and we have to do better.

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    1. Good question. Since I was running the program, I felt it was my job to let the resident do the procedure. In fact, it was an opportunity to teach her how to do it the right way. So I did.

      I agree that many changes in medicine have reduced the exposure of students and residents to procedures. It's a real problem in surgery as I have written on several occasions.

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