Orientation to the Surgery Clerkship

Suggestions for Students on the Surgery Clerkship

           We would like to try to convey some of our general philosophical concerns to the students as they begin their third year clerkship. We expect the students to conduct themselves as physicians in training. As such, they should look like doctors. They should be reasonably groomed, have white coats, come to the hospital each day wearing a shirt and tie for the men and some analogous attire for the women. They should avoid wearing T-shirts, sweat clothes, badges, tennis shoes, soiled clothing, and scrubs when not needed. They should also conduct themselves in the presence of patients and their families just as they would expect a physician to conduct him or herself if they themselves were the patients.

Main Doctor Concept

            Generally the students who will be thought of as the best in their ward work will be those that throw themselves into the fray helping out with whatever chores come along. They should orient their greatest attention around the patients that they have been personally assigned, taking on these patients as though they are the only house officer involved (the “main doctor” concept). Students often resist the idea of helping out with the chores confronting the service, but the reasons for this resistance have remained mysterious to me. Even the faculty members are each willing to help the others out as needed with cases, coverage, phone calls, etc., and the students certainly should be willing to have the same spirit of community work. On a different note, there is no patient care activity that is not educational. One can never learn enough about being an expert blood drawer or IV starter. One can never learn enough about how best to take care of patients as these procedures are done. These activities are very important to optimal patient care and there is no better time to become an expert in these matters than during medical school.
            Students should strive to go with their patients to the operating room. The operating room holds several interesting opportunities for the students. First and foremost, they will probably never spend very much time there again, and this is an opportunity to see anatomy in action and to see procedures being done that one would refer their patients for at later times. It is amazing the perspective one can gain about CT scans or other studies when correlating this with the real life view. Also, the operating room supplies the best overall access to the faculty. Often with schedules being hectic for the faculty, clinical demands, committee meetings, paperwork, etc., the primary time for interaction can become times in the operating room. The students should feel free to ask questions of the faculty and residents. Students should come to the operating room prepared as well as possible. Even a few minutes spent just prior to entering the operating room reviewing the case in question will be enormously beneficial. The OR experience is perhaps the best overall example in the surgical environment of the concept of the efficiency of learning. During the early part of medical school one is exposed to enormous volumes of material, some of which can be learned for a few days or weeks and can be regurgitated on exams. However, the retention of this type of information is low. On the other hand, during clinical times when one sees a specific patient under specific circumstances and has prepared for this case the principles and concepts learned will usually be stamped indelibly in one's memory forever. Thus, this becomes the most efficient form of learning.

Asking Questions

            Students have told us that they are concerned about asking too many questions. They fear that the questions will be used in turn to evaluate them.  We would urge you not to take this position but rather to begin a dialogue of questions just as you would interact with a friend who is involved in an activity that you are not completely familiar with. We are keenly aware that you cannot possibly know all that we would like you to eventually know as third year medical students. We would like to do as much as we can to help you learn these things. Most of the evaluation that occurs from the interaction between the faculty and residents with the student as far as grades are concerned has to do with the enthusiasm, interest, and energy displayed by the student on the wards and not by their exact fund of knowledge during the clerkship. It is our assumption that your fund of knowledge is virtually zero at the beginning of the clerkship and will grow to a -satisfactory amount by the end of the clerkship and will be tested and demonstrated more on the tests at the end of the clerkship and less during the clerkship.

Conferences

            Students should strive to attend the available conferences. It is mandatory that students attend morbidity and mortality conference and Grand Rounds. The schedule for these conferences is available weekly and the residents on your service will know exactly when these conferences are scheduled. It is also imperative that the students attend the morning lectures.
            Virtually every service has its own conference which would of course be mandatory for the students working on that service at that time also. Finally, there are a few other conferences worth taking note of. Every Wednesday morning at 6AM  the residents have a conference that is part of their didactic educational system. The students are invited.  Most Thursday evenings there is some sort of educational activity for the residents and the students can often take advantage of these educational opportunities as well. These include seminars on teaching, technique labs, and journal clubs. Similarly, we hope most students will take advantage of the student techniques labs.

Reading

            Obviously with a hectic schedule of work, OR, conferences, and other demands, studying seems to take a back seat. Students must realize that they will never again have the huge blocks of time in the evenings and on the weekends to study that they had when they were in the first two years of medical school or in college. Welcome to the rest of your life! You must develop techniques and habits that will allow you to flourish in this new environment because the environment that you see during your third year is the environment that you will live in the rest of your professional career. You must be able to study in shorter blocks and picking up on scrap pieces of time. You must learn to work and read when you are tired. This is the way of life of physicians. There are several ways to overcome what at first seems a formidable obstacle. First and foremost, be relentless in your pursuit of knowledge. Do not passively set back and expect that you will learn what you need to know just by hanging around. This is one of the great myths of clinical activity. You should be actively reading at all times. Your priority should be on reading about the patients that you are taking care of and the experiences that you are undergoing at any given time. This will maximize the efficiency of learning discussed above. Try to read the Lawrence book in its entirety. This book was developed utilizing a survey asking many people in many aspects of medicine what they thought students should learn during the third year of medical school in surgery. This book is readable and it can be read during the clerkship. Some of your testing will come directly from this book and the associated educational materials. Feel free to read more at length in other books as well. Favorites include Dr. Way's text which is part of the Lange series, Dr. Hardy's Textbook of Surgery, Dr. Sabiston's Essentials of Surgery, and the NMS Outline Series. You should take these books and tear them up. I know this sounds outrageous, but you will never use these books as reference books. Rather, they should be workbooks. If you tear them into chapters you can easily keep a chapter with you at all times. You will be astonished how much time there is to get through sections of these books while waiting for a conference to start, waiting for a patient to be anesthetized, waiting for rounds to begin, during other breaks during the day, and at all sorts of other bits and pieces of scrap time. Another fun item that lends itself very well to this type of study is the Saunder's Surgical Study Cards. Many of us have found them very useful when studying for our Boards, and I believe that you can easily get through the whole box by carrying three or four around with you each day during your clerkship. Also, the students who have preceded you have developed the Leslie Rudolf study guide which I believe you will like very much.

Sleep

            Another trick for studying is to begin to take advantage of morning time. It may sound outrageous to get up even earlier than you have to get up now, but many of us have found that this is the only way to deal with long days on our feet and the need to do paperwork. Many of us have found that it is impossible to get studying or paperwork done at the end of a long exhausting day. Rather, as soon as we get through with the day, we visit with our families, get a bite to eat, and get to bed as early as possible and set our alarm clock to wake up five to six hours later. Even with long days this often means that you can get up at 4 or 5 o'clock and, if you are lucky, you could conceivably get up as early as 3 a.m. This leaves you with some amazingly good quality study time in the mornings. One also needs to take advantage of the weekends for study. Do not succumb to the myth that one can sleep late on the weekends to make up for lost sleep during the week. This approach is very counterproductive. One should get up at the same time everyday and you will feel better each and every day.
            We certainly expect all of our students to be mature graduate students while they are in medical school. It is our fear that this maturity that was evolving as seniors in college is repressed during the first two years of medical school in which very detailed instructions are given about lectures, questions, tests, areas of responsibility, what text to read, etc. We would like to see our students shift back into the graduate student mode or the college senior mode in which they take more responsibility for their own education realizing that it is contrived at best and unfair at worst for faculty to tell students exactly what they are responsible for. Basically throughout the third year and throughout the rest of their education what students are responsible for is their patient's care. The education that will be required to provide that care is partly defined by the students themselves.

            Doug Newburg and I or others on the faculty will be happy to talk with you as a group or as individuals as the rotation goes along. You should also take advantage of your advisors to help with getting advice on other aspects of the clerkship.