Much like the other rotations, students act as part of a specific team, usually consisting of one Chief Resident, one Senior Resident, and one or two Interns. The hierarchy is that the chief resident operates much of the time but still is ultimately responsible, along with the patient's attending surgeon, for the patients on his or her service; the senior resident also operates a good deal of the time but the senior resident also conducts morning and afternoon rounds with the team; the interns operate on relatively minor cases and spend most of their time on the floor managing the patients pre and post operatively under the supervision of the more senior residents and the attending staff. On rounds, you are generally reporting to the chief/senior residents and the interns.
Each team has a separate focus.
- Hepatobiliary/Endocrine Surgery Service (RED)
- General Surgery/Laparoscopic Surgery (GOLD)
- Colorectal Surgery (BLUE)
- General Surgery (ALLEN)
Although the Allen Pavilion rotation is known as a less intense service, students there sometimes find themselves with a very heavy workload. In short, there is no reliable way to predict the characteristics of each service before the rotation begins.
On the first day of the rotation each student picks a piece of paper with the name of the assigned service from an envelope, so it is totally random. Students are allowed to switch teams, but most do not.
Students are assigned patients on whom they will round and write notes. Every morning each student will pre-round: check vitals, perform a focused physical, change dressings as needed, devise a daily plan, and write a SOAP note for each assigned patient. SOAP notes in Surgery should be less than one page. The first line should include the number of days post-op and the names of any antibiotics the patient is taking, along with the number of days they have been on each. Also important to include in the note is the patient's fluid input and output. Otherwise, Surgery notes are similar to SOAP notes in Medicine and other rotations. Students rotting through Surgery early in the year should allow approximately 25-30 minutes per patient to pre-round. Later in the year, when clinical clerks are more efficient, 15 minutes per patient is usually adequate. On work rounds the students report to the team on the status of each patient, including changes on physical exam, results of new labs or other studies, and then present a plan for the day. The student's most important responsibility is to help the team stay on top of each patient. If the student performs this job well, then the entire team looks good and things go more smoothly for everyone.
Each student is expected to know the history, current physical, what the consults' notes say, and lab values for their patients at all times. These patients also have interns assigned to them so it is important to share information with the intern covering your patients. Most likely the intern already knows if Mr. X spiked a fever last night—but do not spring surprises on rounds. In other words, do not sabotage your intern in front of the senior resident; rather, work with the intern. Perhaps in contrast to some other rotations, you are considered a vital part of the team in surgery: the team is depending on you to write the SOAP note before rounds. You are basically saving work for the interns who would otherwise be responsible for writing all the notes on the service. Your chance to shine is by presenting your patients in a concise and accurate manner and having a good plan for your patients each day.
In addition, students will attend all the operative procedures on their patients and should also see procedures on other teams so they can get a good feel for the various types of operations done by general surgeons. A motivated student can also see other operations, such as cardiothoracic, and vascular or transplant procedures. Some residents will not want you to leave the team to see other surgeries, but after the second week you should be spending at least part of your time seeing some of the required procedures not done on your specific team.
For most surgeons, your scrubbing in provides an excellent opportunity for you to be involved and really learns what is going on in each procedure. At least one assigned student is expected to be present and scrubbed in from the start of every operation, when possible. After the operation is over, the student who assisted is expected to help the residents undrape the patient, and go with them to the Recovery Room, write post-op notes and orders. Whenever possible, it is beneficial to prepare for each surgery by reviewing the operation to be performed, the relevant anatomy, and the indications for the procedure. In addition, a review of each patient's chart before the start of the procedure is important, as attendings will often ask questions specific to that patient's history. Attendings also prefer that you introduce yourself to the patient if you are going to see the patient before the operation.
The student's responsibilities during procedures depend on the attending and the procedure. Chiefly, students are asked to cut sutures and hold retractors. On some occasions students are allowed to make incisions, suture wounds, tie off blood vessels, and even do some small amounts of dissection. It is important to remember that surgery is a hands-on field, so standing back and watching is not very beneficial. Students should try to feel tumors and explore the normal and abnormal anatomy. As a matter of etiquette, it is important to ask permission from the attending before reaching into the operative field; however most surgeons will not only allow exploration of the operating field but also will encourage it.
Using your PD system, you are expected to record all the surgical procedures you have attended and all the procedures you have performed, both in and out of the operating room. You should enter your data as soon after the encounter as it is much more difficult to go back and attempt to remember the procedures than it is to record them at the time.
Students usually participate in afternoon rounds with the team if they are not in lecture or at a preceptor sessions. Usually, afternoon rounds are held after the full team has finished the operative cases for the day, but often the chief resident or the senior resident is still tied up operating and the rest of the team makes the rounds. You should pre-round on your patients just as in the morning, except you don't have to write a note unless there are significant changes. Afternoon rounds are often sit-down rounds, as opposed to the morning where you do bedside rounds on all the patients. You may visit only a few of the patients in the evening.
The Surgery Clerkship has a more extensive examination program than other rotations, consisting of both written and oral components. The Shelf Exam (written) portion consists of approximately 100 multiple-choice questions; the oral exam is composed of clinical scenarios related to the cases and material you have studied. In the end, the exams do not account for a large portion of your grade, but they must be passed.