A Day in the Life of a Surgery Clerkship Student

The surgical clerkship is one of the most important rotations students have during their third year of medical school. It’s not only one of the most rigorous clinical rotations, but it’s also an eye-opening experience that helps students realize if surgery is really what they want to do with their lives. While each student’s experience may differ slightly, there are some aspects of the surgery clerkship that remain consistent across all of them: long days, a lot of anatomy to learn and memorize, and at least one or two amusing anecdotes to bring back and tell your classmates. As former pharmacy students, you will more than likely be disappointed with the amount of pharmacy skill utilized in this practice setting I can't say I was expecting much but you really don't touch medication principles at all. I personally struggled to find relatable content, however that's not to say it doesn't exist. In episode 5 of The Physician Pharmacist Podcast, Dr. Thomas Melvin, a fellow Physician Pharmacist and current cardiothoracic surgery fellow rebukes such comments. If you are interested in hearing more about the surgical theater check out his interview!

Arrive Early:

There's no getting around this. While most medical school rotations start in the early hours of the day, very few start as early as the surgical specialists. As you will come to know, attempting to maintain a timely OR schedule is essential if you want to leave before the 7pm. To make that happen, the surgical team often meets around 6am to round on the patients, discuss management, and go over the cases for the day. As a medical student/resident, this means you need to arrive far earlier to prepare your presentations for the attending physician. Depending on how many patients you have on your service, this may require a 4am alarm clock (especially if you live far away from the hospital like myself). Also note that most surgical clerkships are 6 days a week! Kiss those free Saturdays goodbye.

Pre-round on Patients:

It is often an expectation on surgical clerkships to "pre-round" on your patients prior to morning Rounds. As mentioned you will need to arrive ridiculously early in the morning to have ample time to review the patients chart to get updates on medical management. The patients you review are often assigned the prior night, along with the cases you are expected to assist with for the day. Paradoxically, the more proficient you get the more patients you will get assigned. While more work isn't always appreciated, especially as a busy medical student, it can result in excellent preceptor reviews at the conclusion of your rotation.

Once you have written down the pertinent vitals, labs, and new findings you are then expected to go see your patient and conduct an exam. Depending on attending/fellow preference, you may not have to physically visit the patient to avoid disturbing them in the early hours of the day. If you are expected to go, I always recommend you find the patient's nurse to get personal patient updates that may have been left out of the chart.

You are probably wondering what kind of patient's you will have on your floor! Unlike medicine, all of your patients will be post-operative patients who were admitted for post surgical care. Sounds obvious, but it's important to keep things in perspective. Your goal is to get patients out of the hospital as fast as possible. As you know, turning a hospital ward into a long-term-care setting results in worse patient outcomes including higher rates of nosocomial infections.

Think to yourself, "what is keeping this patient in the hospital right now?" The most common reasons are post-operative pain control and post-operative ileus (sleepy gut). Once you've established your core reasons for hospitalization, you can optimize your plan to approach such things (all while impressing your attending). Focus on the following;

• Early mobilization (Out-Of-Bed to Chair)/PT/OT Recommendations

• Opioids to Non-Opioid Pain Control

• Epidural Management and Removal

• NG Tube Output/Bowel Movements

• Foley Output

• Surgical Incision Monitoring

• DVT Prophylaxis

The rest of your problems will be highly specific to the type of surgical care you are providing. For example, if you are dealing with trauma patients, you'll have to tackle the aforementioned material along with wound vacuum care and initiate constant wound re-dressing.

Attend Morning Lecture:

There is typically a dedicated day each week where the whole surgical service will meet up for presentations and educational lectures. They put the whole OR schedule on hold for these events, meaning it's a pretty big deal! These meetings are often termed "Morbidity and Mortality Rounds" (aka M&M Rounds). While most presentations are put forth by surgical residents (especially the chiefs of each respective service) you may find yourself presenting at a conference if requested. This can be both an opportunity to impress surgical faculty but you will need to be ready to field several difficult follow-up questions (often by the Chief Attending of the Surgical Department).

The material discussed at M&M can be pretty interesting as they often discuss cases from earlier in the week/month where their was an ambiguous medical decision, a unique case, or a blatant mistake that warranted discussion with the department. As you progress through your clerkship you may see some of your own patients brought up for discussion which can make the M&M conferences feel far more person! After M&M there is sometimes a more formal educational lecture presented by a younger surgical resident (often a 3rd year). While patient's are included in the discussion, it often circulates around standards of practice and potentially addresses nuances of emerging technology in a specific field of surgery. These are the sessions you may want to take notes on to help you during your rotation, however the principles discussed are usually not seen on the Shelf Exam at the conclusion of your rotation.

Scrub in for Surgery:

If this is your first day of surgery and you've never scrubbed in before, do yourself a favor and watch a YouTube video explaining how to do it. Also review standard practices in the OR such as "how to avoid violating the sterile field" or "common OR mistakes." The team takes this extremely serious and you should too. I had a case where a staff member broke sterile and contaminated the surgical field just as we where about to break skin. The whole set-up had to be scrapped and reset. I know what you are thinking, and no it wasn't me who did that...jeez, no faith in The Physician Pharmacist I see! In the end, the case was delayed an entire hour, and put us behind for the rest of the day. Don't be that medical student!

Common mistakes:

• Never intercept a sharp even if it seems like the nice thing to do to aid your busy srub tech/nurse. An increase in the number of "sharp transfers" is proportional to the rise in needle sticks/accidents. If you are holding a sharp, call it out to the team such as "needle back" or "unprotected sharp."

• Don't itch your face or move your glasses. Now I am guilty of this one. We do it so often without thinking that it can be sometimes hard to consciously notice your habit until it's too late!

• Don't try to catch falling object. Let them go, but call them out! If you get in the habit of reaching for items, it might just be the scissors, a suture needle, or open syringe that you may instinctively grab and unfortunately stick yourself.

• When the scrub tech helps you put your sterile gloves on, don't jam your hand in. A nice causal insertion actually prevents screwing up the gloving process. Try it, I swear it works!

• Scrubbing your hands in the sink then accidently touching the faucet handle, wall next to you, or the sink itself. You just contaminated yourself and need to start over the sterile scrub process all over again.

• Scrubbing in after the attending. You'll start to pick up on the social cues but as the attending starts to prep the patient that's usually your signal to scrub. The goal being that you are ready to go at the patients side so that your attending can make their dramatic red-carpet level entrance!

Also keep in mind that the scrub nurse can be your best friend or worst nightmare (partly because your mistakes typically affect them the most). Always introduce yourself at the start of a case and bring them your gown and gloves. These minor gestures actually go a long way and can make your experience in the surgical theater so much better, especially since you will likely work with everyone for several weeks of time.

Now that we have covered some surgical etiquette, we can further discuss the physical act operating. At this point you should be familiar with the case you are assisting on (since you were such a good student and looked up the anatomy the night prior). You should be prepared to get "pimped" with basic anatomy questions including important landmarks and danger zones. Once the case is underway you may be asked to hold retractors, use the electrocautery (Bovie®️), throw stiches, and most commonly close the patient up at the end.

Also note that it's usually a good idea to see how long your case typically runs. A good rule of thumb is to check when your next scheduled case is for the day. If you don't see one, you are either really lucky, or more than likely you are scheduled for long-haul surgery. My longest case was 9.5 hours and I had no idea what to expect prior to scrubbing in for it. Mental preparation for these long-hauls can really help with morale! If you can't find a good resource online, you can always ask Anesthesia. One of their many roles includes maintaining the OR schedule, especially since nothing can start without them. With that said, they need to have pretty good estimates for procedure length/time to ensure adequate staffing and a relatively seamless transitions to the next case.

Lunch Break

Just kidding! Did you really think surgeons have time to eat? Meals are for the weak-hearted. Your passion for surgery alone should provide you with enough sustenance to complete the day. All jokes aside, it can be challenging to make time for a sit-down lunch but a quick coffee/snack break isn't outside of the possibilities.

Running the List

Depending on what you are assigned, your cases may end prior to your scheduled 12 hour shift conclusion time. If that's the case you will have to help write notes or provide hands-on floor visits to fix wound packing and faulty wound vacuums. The team is usually stretched thin and relies on medical student help!

Once things are packaged up nicely the team often "Run's the List" to ensure that everyone is on the same page for management, discharge planning, and rehab. This is essentially the "second rounds" of the day but is often run by a senior resident (not an attending). Here they delegate tasks, check on the status of daily progress notes, and try with all the power in their being to figure out how to make the list smaller by discharging patients. An honorable yet challenging task! Do you want to know who a surgeons best friend is? A proactive physical therapist who clears people for discharge.

Study for Your Shelf Exam:

Feeling blessed as that final minute of your 12 hour shift slips by and you are finally free to go. As an individual with very little interest in surgery at this point in my career, I advocate that you get out as quick as you can. There seems to be a tendency for complicated cases or consults to roll through the door just as your heading out and you may not want to get roped in! If you plan on becoming a surgeon you should probably stick around though!

You have now escaped the hospital and can finally rest your legs, plop down on the couch, and flip on some mindless TV after a long day on the job. What a relief right? Just kidding! You still have 3 more hours of UWorld exam questions to do in preparation for your Shelf Exam and Practice (OSCE)! Ah the life of a medical student! Make sure you plan out your study schedule ahead of time to ensure you can complete all the necessary work, while maintaining your busy work schedule. As mentioned, you usually lose part of your weekend which also makes cramming more difficult! Do a little work everyday and it will pay off in the end.

Finally, go to bed and repeat the whole thing again the next day! Don't forget to review your cases that you were assigned for the next morning.

Conclusion:

With all jokes aside, surgery is a very challenging yet rewarding field to work in. You are highly respected (as long as you don't adopt the academic god complex mentality) and make a serious impact in patient lives. I personally disliked surgery due to the "work-work-work-maybe some life" balance, but I appreciate all those who do it. A serious sacrifice for the profession you love!

Also note that your time spent on a surgical clerkship doesn't go unnoticed. We often serve as integral members of the team that can help reduce the workload for the tired staff and residents. While it may seem bleak from moment to moment, I know for a fact that the resident truly appreciate your help, even if it's just one less note they need to write! Lastly, you will have the opportunity to make great friends along the way (possibly from the shared-trauma...just kidding)!

In this article, we covered a standard day in the life of a medical student on their surgical clerkship. Although my slight bias against surgery may have painted a bleak picture of the practice, I want you to know that it's not all bad and that it can be a very fulfilling/enjoyable field to work in! If you’re considering pursuing a career in surgery, I applaud you for your durability and perseverance!

Check out my personal Surgical Notebook Guide I used to keep my thoughts organized and improve my presentation format!

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