December 22, 2022
After reading this resource, medical students should be able to:
We get it. Preparing for the surgery clerkship—a rotation known for its long hours and unfamiliar culture—can be daunting for medical students.1,2 Moreover, operating room (OR) protocol as well as an emphasis on self-directed learning often leaves students uncertain of what to expect in their daily schedule and how to best plan. Efficient routines, focused preparation, and disciplined self-care enable students to perform at their best and enjoy their surgery clerkship. Even for students who plan to pursue a non-surgical career, the surgery clerkship is an opportunity to learn the entire spectrum of medical and surgical management while simultaneously practicing teamwork and hands-on skills.3 In this resource, we provide recommendations grounded in firsthand experiences and medical education theories to assist medical students in preparing for and excelling in their surgery clerkship.
At most institutions, students should expect to work hard during their surgery clerkship, as they adjust to OR etiquette, earlier mornings, and a multilayered knowledge base. In return for consistent effort, students can expect positive outcomes in their relationships with patients, in their evaluations from team members, and in their own learner satisfaction. In our experiences, students have the most confusion about the schedule, team structure, and surgical culture of the surgical clerkship.
While hours vary based on the specific rotation, rounds commonly begin around 6:00 am. If pre-rounding on patients beforehand, students can allot 20–30 minutes per patient to start, understanding they will become more efficient with time. Surgical cases typically begin around 7:30 am, and students may be assigned multiple cases with brief breaks in between. Students will be dismissed home after their cases finish and/or after afternoon rounds or evening sign-out (6:00 pm).
Typically students will work closely with the intern on patient care and floor tasks. The senior resident will assign cases, direct patient care, and spend most of their time in the OR. Students may be assigned to the OR alongside another resident, who is an excellent resource for questions and guidance throughout the cases.
While the surgery clerkship is a demanding and, at times, uncomfortable experience, students should not experience mistreatment and disrespect.4–6 Students are encouraged to speak to a trusted advisor or clerkship director if this occurs. Developing early relationships with residents and patients has been shown to improve the student experience in the surgical clerkship.7
A critical component of the surgery clerkship is assisting with patient care on the floor. Students can be helpful to the surgical team by taking on level-appropriate tasks and understanding basic perioperative complications and management.
Students are generally expected to pre-round on their patients prior to rounds each morning. Pre-rounding should include reviewing overnight events and patient data in the OMR, getting report from the overnight resident if applicable, and visiting their patients to get their subjective report of the night (pain control, new symptoms, etc.) and perform a focused physical exam. During morning rounds, students should plan to give a brief oral presentation on their patient(s) to the team. This report should include a one-liner, overnight events, subjective details, fluid intake and output, vitals and physical exam, relevant data (new labs, imaging, or microbiology results), patient assessment, and plan for the day (clarify the format and level of detail with your team beforehand). Students can carry supplies in their pockets and white coats to be prepared for tasks as they arise during rounds or throughout the day, such as changing a dressing or flushing a nasogastric tube (Figure 1). After rounds, students may be asked to help with various floor tasks such as writing progress notes, calling consults, communicating with nursing staff, and performing postoperative checks. As students grow in efficiency and competence, they may take on more tasks and responsibilities, eventually becoming more proactive and independent.
Supplies |
Description |
Function |
Flushes
|
10 mL syringes of normal saline
|
Flushing lines/NG tubes, washing wounds, wetting dressings
|
Gauze of various sizes
|
May be called “dressing sponge.” 4- x 4-inch used most often
|
General wound care and dressings
|
Kerlix Wrap
|
Roll of gauze-like material
|
General wound care and dressings
|
Abdominal pads
|
“ABDs,” large soft dressing pads
|
General wound care and dressings
|
Drain sponge
|
Gauze-like material with center hole for drain
|
Dressing drains
|
Tape
|
Paper tape and a plastic-like version
|
General wound care and dressings
|
Suture removal kit
|
Kit with scissors and forceps
|
Taking down dressings
|
Sterile Q tips
|
Simple Q tips
|
Dressing wounds
|
ACE Bandage
|
Brown stretchy wrap
|
Dressing wounds
|
Tegaderm
|
Clear sticker
|
Seale gauze, line insertions
|
Xeroform
|
Lubricated yellow dressing
|
Occlusive dressing
|
Students should learn about perioperative management and common issues that arise, including postoperative pain, urinary retention, ileus, infection, and electrolyte/nutrition imbalance. These topics are widely applicable to other medical specialties besides surgical ones and will help the student become a better physician overall. Students will quickly learn these topics through direct patient care and may supplement this learning by consulting resources such as OnlineMedEd or Dr. Pestana’s surgery notes.8,9
One of the primary expectations for medical students on the core surgery clerkship is to come to the OR prepared. A simple framework that clerkship-level medical students can use to guide their preparation is to know the patient, know the procedure, and know the anatomy.
Before the operation, students can read about their patient’s history in the electronic health record. They should focus on the patient’s initial presentation for surgical treatment and what work-up they have received, including labs, imaging, and staging. The patient’s past medical and surgical history, social history (substance use, functional status, occupation, home support), and medications are all pertinent to the operation and the postoperative care plan.
Students are not expected to know all steps of every operation. Instead, they should consider the following components: why does this patient need this particular operation, what is the intended outcome of the procedure and what are the basic steps needed to achieve that outcome, and, finally, what are common intraoperative and postoperative complications that may arise. Students may also consider reviewing prior operative notes for the upcoming procedure, which has an added benefit if the operative note was created by the surgeon who will be performing the case. A great resource that students can use to prepare for all relevant components of an operation is Zollinger’s Atlas of Surgical Operations, which can generally be accessed for free through an institutional login. Specific chapters correspond to specific surgeries that are frequently encountered. Current Surgical Therapy is another utilized resource. 10,11
Medical students are frequently asked about relevant anatomy in the OR. To prepare, students should consider the function of the organ or structures that are being operated on and how the operation will affect that function. Students should review the key arterial supply, venous drainage, and innervation of the major structures relevant to the operation. Finally, they should consider the important surrounding structures that could be injured during the case. Much of this can simply be looked up online, but Moore’s Clinically Oriented Anatomy is a commonly used, clinically-relevant anatomy resource.12
While this is a lot of information to study before each operation, students should start with knowing the patient and progress to knowing the procedure and anatomy as they are able. Over the course of the clerkship, students will gradually build up their knowledge base as they see an operation multiple times.
While students often fear being asked questions in the OR, this is an expected and integral component of surgical learning. Questions offer students the opportunity to demonstrate knowledge and to identify their specific knowledge gaps. It is not expected that students will know every answer, and many surgeons ask questions to understand students’ knowledge levels and then offer relevant and useful teaching accordingly. Students are also encouraged to ask questions during downtime before and after the operation, and during parts of the operation when the situation allows such as the opening and closing phases.
As in all fields of medicine, students may, unfortunately, come across physicians who are not good educators.3 Students can notify their clerkship director or advisor about interactions and/or educators that detract from their rotation experience. Issues of professionalism and respect should be taken seriously and elevated accordingly.
In many programs, the core surgery clerkship can be a logistically and emotionally intense time for students, regardless of intended specialty.6 Optimizing performance and well-being on the clerkship should not only entail academic preparation but also thoughtful scheduling of meals, social time, studying time, exercise, and personal rest. The following list is intended to provide practical suggestions for maintaining balance based on our collective experiences.
Performing well on the Surgery NBME Subject Exam is achieved through selection of foundational and supplementary resources, a well-planned study schedule, thoughtful review of chosen question banks, and integration of knowledge gained both in the surgical and medicine clerkships. Importantly, the education literature confirms that excellent clinical performance on the surgical clerkship is reflected in Subject Exam success.17
Prior to their clerkship, students should select 1 question bank, 1 recommended foundational textbook, and 1–2 supplementary resources, with the question bank being the most important resource (Figure 2). Attempting to utilize too many resources can result in poor retention as well as an inability to keep pace with a study schedule. Following selection of the materials, a study schedule should be created (via Excel, calendar app) that prioritizes completion of the question bank in the clerkship time interval and realistically integrates relevant supplemental material.
Name |
Resource Type |
Description/Use |
U World20 |
“Step 2 CK and Shelf Exam” Question Bank
|
Often regarded as the “gold standard” for subject exam study prep
|
Amboss21 |
“Step 2 CK” Question Bank/supplementary resource
|
Can use as an alternative question bank or reference the learning cards for important topics
|
Surgery: A Case Based Clinical Review (DeVirgilio)22 |
Textbook
|
May skim relevant chapters regarding perioperative care of relevant topics
|
Dr. Pestana’s Surgery Notes9 |
Textbook
|
Excellent, quick read for broad overview of surgical topics
|
Online MedEd8 |
Supplementary online video resource
|
Quick videos on important surgical topics
|
NBME Subject Exam “Self-Assessments”23 |
Official practice exams for the NBME Subject Exam
|
Helpful to get familiar with the testing format and style of questions. Try to do at least one before your exam.
|
The question bank is necessary and invaluable to success on the Subject Exam and should be used in conjunction with foundational textbooks. Maximizing the utility of this resource can be achieved by:
As the medicine and surgery Subject Exams have significant overlap, investing in the clinical experience in both the medicine and surgical clerkships will not only improve confidence and practical skills, but will also reap critical academic dividends. Additionally, especially if students have not yet had their medicine clerkship, they may find it helpful to review questions from the medicine question banks, particularly those related to the renal and gastrointestinal systems. To supplement the question bank students may read portions of a textbook that focus on presentation, workup, diagnosis, and treatment of common surgical conditions, while various additional resources can be referenced for quick review of key topics. Students should try to complete at least 1 timed practice test, or NBME Subject Exam “Self-Assessment,” to get familiar with the testing format and style of questions.
Notably, some programs may additionally require an oral exam. In addition to the preparation above, we recommend students verbally work through surgical cases with fellow students––paying particular attention to appropriate diagnostic workup and management of common surgical problems.
With these tips in mind, students can excel on the surgical clerkship. As on any rotation, being engaged, understanding your learning needs, and being a good team member are the most important factors for excellent performance. Students should remember to have fun and enjoy the amazing and unique experience of caring for surgical patients.