Becoming a Surgeon and Mastering the Craft

This guest post by Jenna Smith discusses the necessary ingredients for becoming a surgeon.

Individuals pursuing surgery as a career have to have what it takes to handle the job. With a lot of responsibility involved, including having another person’s life in your hands, surgeons have a tremendous amount of pressure to perform well at their jobs. Mastering the craft as much as possible can happen as long as people are willing to put in the work starting from when they’re in school and all the way through to the end of their career.

Learning How to Handle Surgical Equipment
Surgery cannot happen without the proper equipment. It isn’t possible to cut into flesh and fix broken bones without certain utensils and instruments necessary for those types of jobs. Everything from a scalpel to a surgical light needs to be well understood. Watch how others use these items whenever possible, either through video or observation. Another useful tip is to check out resources such as the Surgical Lights Buyers Guide to get acquainted with product details and better understand how to operate the equipment so it works the most efficiently.

Choosing a Specialty
Though general surgery is an option, most people opt for a more specialized field. Plastic surgery, for example, is one of the most sought-after choices in the surgical world. After graduating from college, individuals then must go on to learn at a medical school. A doctor of medicine degree is received after completing four years. During the next three years, hopeful surgeons must complete their residency training. Doctors complete general training first before getting to choose a specialty and focus on only that area. A special certification will need to be obtained to practice surgery in one particular field, such as earning certification through the American Board of Plastic Surgery.

Study, Study, Study
If students think they can go to medical school and never have to study simply because they didn’t study much at their former college, they will be incredibly mistaken. Getting through medical school and preparing to become a surgeon takes a tremendous amount of work. Individuals need to study, study, and study some more if they are going to want to remember all of the information that gets packed into just four years of classes. Medical terminology, proper procedures, hospital rules and regulations, and laws all need to be learned and memorized before school is finished. Having a study system in place will be key to being successful.

Study Some More
Studying for school isn’t the only thing to worry about. Once school is completed, students still need to become certified if they want to practice medicine. The ACLS and PALS tests are two options. If the job specialty you want requires these certifications, then it will take even more studying to prepare for either of them. Finding some good study methods that help retain as much information as possible is important for getting through these exams.

Don’t Forget to Keep Learning
Too many people believe that because they attended medical school and completed all of the required work and hours to become a surgeon, the learning is complete. They have now learned everything they need and can continue to do their job the same way forever. This is not true when it comes to surgery, not to mention medicine in general. Everything is always changing and adapting. New medicines are discovered. New machines are made for efficiency. Doctors must constantly continue learning and adapting to the world of medicine so they can offer the best care.

Becoming a surgeon takes a considerable amount of effort, patience, and desire. People will quickly find out once they start practicing medicine whether they’re truly cut out for the field. With the gruesome tasks, life or death situations, and vast amount of responsibility, only those who can truly master the craft should perform surgery.

Jenna Smith has been blogging since she graduated from the University of Utah.  She finds herself spending less time writing due to a new venture called “MARRIAGE!” She enjoys her new venture very much. Lucky for us, she still finds time to write great articles, including this one.

When Breath Becomes Air by Paul Kalanithi - A Scrub Notes Book Review

"When Breath Becomes Air" is a memoir written by neurosurgeon Paul Kalanithi. The book is a poignant look at the human spirit in both the pursuit of excellence as well as in coming to terms with its own impermanence.

Kalanithi was a Stanford neurosurgery resident when he found himself becoming fatigued, with worsening pain and decreasing weight. A routine chest x-ray discovered multiple lung masses, which were soon proven to be metastatic lung cancer. The book was borne of Kalanithi's other passion, literature, as well as his unfortunately unique perspective as both a healer and now a patient at a time when he was poised to be at the peak of his talents.

The first half of the book details Kalanithi's upbringing and path into medicine. His first love was literature, which he pursued all the way to a master's degree. However, upon further reflection, he felt a desire to pursue medicine after grappling with the question of the intersection of "biology, morality, literature, and philosophy." Since he had initially pursued literature, Kalanithi took two more years to complete the pre-med requirements and then apply to medical school. Accepted at Stanford, he was a fast rising star in the neurosurgery world, despite grueling 100 hour weeks year after year.

The diagnosis, coming near the end of his training, shatters Paul's identity. After striving for close to a decade to become an attending neurosurgeon, his diagnosis is his undoing. He rapidly transitions from physician to patient, and has to learn to let go, to trust in others to have his best interests at heart. The book shows how he meditates that cancer in particular is pernicious in that it makes one mortality both immediate and yet still remote: no longer a hypothetical, but not an immediate reality. Everyone has an answer to what one would do with their last day, but what about one's last decade?

Kalanithi then details the long road back to completing his training, the successes and failures of his treatment, and how he learned to live and ultimately succumb to his fate on his own terms. He died in 2015, leaving behind his wife Lucy and their newborn daughter.

For me, the last part of the book was the most moving, an epilogue written by Lucy about Paul's last days. She charts the uncertainty of his final hours and how he was resilient even while facing the unknown. His final wish was that they see the book to fruition, in which they clearly succeeded.

The book reads like what one would expect of a memoir of a first-time author, but Kalanithi's first rate intellect shines throughout. Even though he never uses the label, it is clear that Kalanithi was a humanist at heart. He does touch upon his wavering relationship with religion. For a reader who questions both their path in healthcare or wants a glimpse of how even the best laid paths can abound with uncertainty, "When Breath Becomes Air" will not disappoint.

Humerus Anatomic Neck vs. Humerus Surgical Neck

One of the most popular posts on this site was a deep dive into the difference between Pope's Blessing and Claw Hand. Who knew anatomy could be so contentious? Admittedly, today's post is likely much less controversial, but I always found the distinction between the anatomic neck of the humerus and the surgical neck of the humerus to be confusing. Well, prepare yourself for today's shallow dive into the subject. Hopefully this will help clarify the distinction between the two. If it's already clear to you, congratulations - at least one of us will benefit from this exercise!

The anatomic neck of the humerus refers to the location of the physeal plate during development. During growth, bone forms at the physeal plate as the child ages. Once the child reaches maturity, the plate closes, usually during puberty. Different growth plates will close at different ages, with well-characterized ranges known for various bony structures. This pattern of plate closure can be used to assess a child's bone age, which can then be compared to their chronological age to assess for any delay in maturation. Returning to the humerus, the anatomic neck is mostly notable as a defined landmark but has less clinical application.

The surgical neck of the humerus refers to the narrowing of the humerus in the proximal diaphysis. The neck abuts the quadrangular space, a potential space formed by the margins of the triceps, teres minor, teres major, and the medial humerus margin (3 Ts + H, as opposed to the more medial triangular space formed by those same 3 Ts, but no H). Since this region is more prone to fracture, that means fractures in this area are more likely to damage the contents of the quadrangular space, namely the axillary nerve and posterior humeral circumflex artery.

By BDB - You can find the picture here. Traced and colored the picture using adobe illustrator., Public Domain, Link

To memorize the difference between the two, you can try a few different ways. First, A for anatomic comes before S for surgical, and the anatomic neck is more proximal on the humerus than the surgical neck. Second, the surgical neck is more often fractured and more likely to have surgical complications, so the name is associated with its clinical relevance.

And that's pretty much it! For me, learning anatomy was much more helpful when I could attach a narrative about some clinical situation in which that anatomy was relevant. Start with a basic framework of the location from a book like Netter's Anatomy and then search for clinical scenarios that help solidify the terminology in your mind. Hope this helps!

 

Books For Third Year Medical Students

We previously covered books for first year medical students and second year medical students. The section on books for USMLE was important enough to merit its own post. But, as third years, you are through with Step 1, you are through with basic sciences, and you're geared up for the clinics. Alas, day 1 comes and goes and you realize: there is still a ton to learn! Where do you go to find all that information?

The books described here are meant to give you a high yield, high impact approach to each core clerkship you take. Ideally, for each clerkship, try to read one book throughly and use one book for case reviews / questions. Here is a break down of the books you should get, rotation by rotation:

Family Medicine

Family Medicine is generally a nice rotation, with students primarily rotating in outpatient clinics. If you have already done pediatrics and internal medicine, family medicine covers many of the same topics, but in the outpatient setting. Preventative care is also much more emphasized. Blueprints Family Medicine does an excellent job of covering the major topics and preparing you for the shelf exam.

Internal Medicine

As discussed in the post on Books for the Internal Medicine Rotation, the three books above are all you need. Pocket Medicine will get you through the wards on a day-to-day basis while the other two are what you need to power through on your nights and weekends to ace the internal medicine shelf exam.

Neurology

Neurology should be on the relatively lighter side of the clerkships, especially if you have taken internal medicine already. Since there are relatively few therapeutics, focus on learning how to differentiate major disease patterns.

Ob/Gyn

My recollection of OB/Gyn is somewhat fuzzy as I took it during fourth year just as interviews were starting up. The major challenge in OB/Gyn as I recall was learning the skills as well as knowing how to work up various conditions (such as an abnormal pap smear). For OB, just remember: almost always the treatment is - deliver the baby!

Pediatrics

Pediatrics is generally a fun rotation (babies!). The books you should get for pediatrics are much like the other rotations. Conceptually, again there is some overlap with internal medicine, but there is much more of an emphasis on congenital and infectious disorders.

Psychiatry

All you need is the book above - First Aid for the Psychiatry Clerkship, Third Edition. 'Nuff said.


Surgery

Surgery can be a challenging rotation for many students. Not only is there the typical fund of knowledge of disease that needs to be learned, but also anatomy needs to be refreshed as well as technical skills acquired. Many students ask - what books could possibly prepare me for the surgery shelf exam? Studying for the surgery shelf exam will be a constant challenge. If you can wait, pre-order the latest edition of Essentials of General Surgery, so that you can get it right when it is published in October 2012. For the NMS, make sure you get the casebook, not the full surgery review.

Wards

Some topics come up routinely on wards, no matter what service you are on. First Aid for the Wards: Fourth Edition is a great book to cover all those topics that might otherwise fall through the cracks.

Hopefully the books listed above will prove as valuable to you as they have to me - best of luck out there in the wilds of the wards!

Updated 2015-12-25

How To Write A SOAP Note For A Surgical Patient

One of the most popular posts on this site regards how to write a SOAP note for a patient. The post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note. For example, the mnemonic OLD CHARTS helps remind you of what to put for the history of a particular symptom, such as "cough."

However, as you rotate through the wards, you realize that each service has its own way of writing a patient note. Knowing the particular format of a note by service is helpful. For example, for inputs/outputs on neonatology, you want to mention the volume per gram weight of the baby, but this measurement is nonsensical on a general surgery service. Therefore, this post aims to describe how to write a SOAP note for a surgical patient. Future posts will cover notes for patients on core services, such as medicine, pediatrics, and OB/GYN. 


As before, the basic format for a note is the SOAP note. SOAP stands for:

Subjective: any information you receive from the patient (history of present illness, past medical history, etc)

Objective: any data, whether in the form of a physical finding during your exam, or lab results

Assessment: diagnoses derived from the history and objective data

Plan: what you intend to do about the diagnoses from your assessment

For surgeons though, rounding is brief and sometimes treated as a loss of time from the OR. An attending surgeon can function just fine with that attitude, but a medical student should not share it in order to excel on the service. The ideal student on surgery should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems.

The surgery note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Surgery Progress Note". Next, note the postoperative day, or POD. If the patient just returned from surgery, denote that day as "POD #0". If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on.

For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about return of regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note.

For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint.  Using a book like Surgical Recall, make yourself aware of the major problems in a post-operative patient (typically, the patients you would be writing notes on). In particular, be aware of fevers in the post-op patient, a very common and potentially very dangerous finding. A simple mnemonic to keep in mind is the 5 Ws for causes of postoperative fever:

WIND - stands for atelectasis, the most common cause of fever on POD #1

WATER - stands for UTI, the most common cause of fever on POD #3

WOUND - stands for wound infection, the most common cause of fever on POD #5

WALK - stands for DVT, the most common cause of fever on POD #7

WEIRD - stands for drug-induced fever or abscess, the most common cause of fever on POD #9 and beyond

For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 101 deg F, note what was done to remedy the fever (if anything). For the I/Os, note the rate of IVF administration and the fluid being administered. Also note the location, amount drained, and quality (serosanguinous, bloody, purulent, etc) of any Jackson-Pratt or JP drains here. The physical exam can be brief, but should include the pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:

GEN - A&O x 3 (alert and oriented to person, place, time)

PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi) 

CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses) 

ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)

WOUND - c/d/i (clean, dry, intact) 

 EXT - no c/c/e (no clubbing, cyanosis, or edema)

  

For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For example, "35yo female s/p lap chole stable on POD#2." For patients with complications, consider adding a clause or another sentence describing the reason for an extended postoperative stay. For a patient with fever, you might say, "Patient developed fever on POD#5, subsequently found to have bilat DVT by duplex US." 


For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Lawrence's Essentials of General Surgery for management. For every patient, include a plan for their fluids/diet, pain control, prophylaxis, and disposition (how are they getting home). For prophylaxis, the major issues to consider are DVT prevention and peptic ulcer prevention. For deep vein thrombosis, thromboembolic deterrent (TED) hose and/or sequential compression devices (SCDs) should suffice. For ulcers, try any proton pump inhibitor (PPI) such as pantoprazole (aka Protonix). 


If you follow this basic structure, you should do just fine as far as SOAP note writing on surgery goes. The key to a surgery SOAP note is simply this: be concise but precise. Or, another way to remember it, is: Just the facts, med student. Just the facts. Good luck!

Updated 2015-12-20

Most Stressful Medical Specialty?

Stress is hard thing to judge within a medical specialty. Various factors play a role in creating stress, from the patients and procedures themselves, to one's work environment and career path. I'm not sure how to weight all these factors, but here's the sense I've gotten from the specialties I've been exposed to. 

5 Most Stressful Medical Specialties

1. General Surgery - perhaps I'm biased by the training, but I think given the career, it seems like a lot of stress, considering the income and hours down the road.

2. OB/Gyn - the training is hard, the hours are long, the liability high, and there's relatively less 'control' / predictability over how patients will do from what I've seen. 

3. Internal Medicine - again, just biased by what I see the residents go through. 

4. Surgical Subspecialties - stressful to train, but I think it gets easier in the career itself.

5. Emergency Medicine - while the career is good, I think the fact that these are 'emergencies' is stress inducing on its own, plus who wants to do overnight shifts when they're 60?

As for the least stressful medical specialty, I don't think you can wrong with the old "ROAD" mnemonic (radiology, ophthalmology, anesthesia, and dermatology). Some people would also throw pathology (heh, PATH / ROAD, get it?) and emergency medicine in there as well. While all are competitive to train for, I think the lifestyle down the road more than makes up for it, leading to less stress overall.

What do you think? Perhaps there are stressful specialties that I just haven't been exposed to?  

Books For Surgery Core Clerkship / Rotation And Shelf Exam

As underclassmen have increasingly started asking me for advice on rotations, I thought I'd put together a few guides on good review books for surgery. The surgery core clerkship / rotation is one of the most important in medical school. The grade you receive on this rotation is on par with your medicine grade and second only to the USMLE Step 1 score in terms of factors that residency program directors evaluate. Your grade will likely be a mix of clinical evaluation and your shelf exam score. However, since the evaluations tend to average out to the same values, the shelf exam is what separates the great students from the good ones.

To do well on the rotation requires the usual medical student qualities of diligence and compassion, but the three main things to know are: know your patient, know your anatomy, and know the procedure. If you know those three things and study hard, you will succeed. But, how does a medical student acquire all that knowledge in short period of time? The key is studying good resources efficiently. Here are my recommendations:


Books For Surgery Core Clerkship / Rotation

For any rotation, I would suggest starting off by reading a clinical vignettes book initially, to get familiar with the cases seen most commonly by the specialty. Then, read a general textbook or review to learn more details about the patients and procedures. Finally, do practice questions in the weeks leading up to the test to solidify your knowledge. These principles are especially important during the surgery core clerkship, when your time is limited. Here are the books I used primarily:

Essentials of General Surgery
by Peter F. Lawrence

This textbook covers the major areas of general surgery in an easy to read fashion. The early chapters on fluids and electrolytes are also important, as many questions on the shelf exam deal with management of patients on the floor.  I read this book during the first half of my surgery clerkship and it served me well.

Case Files Surgery (Second Edition)
by Eugene Toy

If you are familiar with the Case Files series, then you know that these books are a good way to get up to speed on any clerkship. They are quick to read, but really help you understand the basic concepts and cases within a specialty. Read this book right before your rotation starts or during the first week. 

NMS Surgery Casebook

by Bruce E. Jarrell

An excellent book full of different cases and their variations. I personally liked the clinical case format, especially how the book managed to discuss common complications. The pictures and diagrams are also quite helpful.

Surgical Recall (Recall Series)

by Lorne H. Blackbourne

This book is particularly handy while you are on service with some time to spare, like me on my minimally invasive (ie bariatric / laparoscopic) surgery rotation. Put it in your whitecoat pocket and pull it out during those little pauses during the day. Flip to the section that covers your next case, and learn all the answers to common pimp questions. You'll look like a rockstar in the OR. 

Other Books For Surgery Core Clerkship / Rotation

For me, these books either overlapped with the ones I listed above, or were too advanced for my tastes. However, if you are interested in surgery or want to honor the surgery clerkship, then it is worth considering whether you want to obtain these texts. Sorry to those of you who see the list twice; the images do not show up in some browsers. 

• First Aid for the Surgery Clerkship (First Aid Series)
  
• Schwartz's Principles of Surgery
  
• Sabiston Textbook of Surgery

If you are interested in good books for other rotations, check out Books For Pediatrics Rotation / Clerkship And Shelf Exam.

Find other books useful on your surgery clerkship? What books helped you the most on the surgery shelf exam? Share your knowledge!

Updated 2015-12-18

How To Scrub For Surgery

Scrubbing into an OR is part of any medical school education, but one that does not seem to be formally discussed much. A medical student's first time in an OR can be an intimidating experience for this reason. The OR has its own rules and culture, which may seem byzantine at first to the uninitiated. For me, the worst part was getting into the OR: specifically, how do I scrub for surgery?

I've tried to address this previously in posts like:

• Tips On Scrubbing In
• Tips On Scrubbing In, Part 2

Perhaps you might be wondering why I am so concerned about scrubbing for surgery. Well, hearing about my first time might explain. The experience was horrible. I was doing a 1 month rotation in Mexico City, Mexico between my first and second years of medical school. I had never been in an OR before, much less on a rotation of any kind. Even though I had watched people in scrub in several times before I ever had to, there were all sorts of subtleties that escaped my notice. When my time finally came, the attending simply said "Go scrub" in Spanish with no instructions. The washing wasn't too bad, but putting on the gown was a disaster. I did not understand what to put on first, what I could touch, how to turn. The nurses tried to help, but I was already stressed and my Spanish wasn't that good! The instructions yelled in Spanish just confused me more! Finally, after struggling for a few minutes, I managed to get scrubbed in, but you can imagine how little confidence the surgeon had in me after that performance. While my little mistakes are no match for those of a resident placing a central line for the first time (as described in 'Complications' by surgeon Atul Gawande), they still left an indelible impression on me. Entering an OR for a laparoscopic procedure (heh, or IR suite) is not so daunting these days, but I'll never forget my first time!

Updated 2015-12-18

First U.S. Face Transplant

The NYTimes has a story on the first U.S. face transplant. As interesting as this is, I still can't get over the results of the world's first face transplant (which occurred in France). The picture on the left is the patient Isabelle Dinoire immediately after the post-op, whereas on the right is one year later:

Not bad, right? Honestly, I had some kind of Frankenstein idea in my head about what a face transplant would look like, or perhaps something from Face Off, but this isn't so bad. It's more like a skin flap that just happens to be on the face. Hopefully this stays in the realm of reconstructive surgery, and never becomes something viewed as cosmetic. 

(Image Source: BBC News)

Anthony Walter: Orthopedic Surgeon or Renaissance Master?

NYTimes.com recently featured a piece on retired orthopedic surgeon Anthony Walter. My favorite line from "At Houston Surgeon’s Home, an Ode to His Wife and to God":

He said their reaction was understandable, given that the museum’s collection includes abstract art, which he disdains. “I am a huge threat because what I have done renders everything they have junk,” he said beneath the glinting chandeliers in his great hall. “I hope that doesn’t sound arrogant but the reaction of people who come in here tells me the power of it.”

Yes, of course. A huge threat. lol. No wonder some people subscribe to a certain stereotype of orthopedic surgeons! Reminds me of that joke about Larry Ellison, the CEO of Oracle Software: what's the difference between Larry Ellison and God?

God doesn't think he's Larry Ellison!

Toga: Endoscopic Weight Loss Surgery

Weight loss surgery has turned into big business within medicine. Bariatric surgery has gone from the butt of a joke within surgery to a full-fledged subspecialty. Interesting article in the NYTimes today about what might possibly become the latest fad in bariatric surgery: endoscopic stapling.

The product described here, Toga, has not been approved yet in the United States, but it sounds intriguing:

On a recent Wednesday, Karleen Perez lay unconscious on an operating table in Upper Manhattan while her surgeons and two consultants from a medical device company peered at an overhead monitor that displayed images from inside her digestive tract.

The surgeons, Dr. Marc Bessler and Dr. Daniel Davis, had just stapled her stomach to form a thumb-sized tube that would hold only a small amount of food. The operation resembled others done for weight loss, with one huge difference. In Ms. Perez’s case, there was no cutting. Instead, the surgeons had passed the stapler down her throat and stapled her stomach from the inside.

What does the procedure itself entail, you ask?

The operation is not as simple as it might sound. To begin, Ms. Perez was given general anesthesia and put on a respirator. Then the surgeons pushed a dilator, a formidable-looking tube about three-quarters of an inch wide, down her throat to stretch her esophagus.

Next came another wide tube, this one about two feet long, containing the stapler. The surgeons inflated her stomach with carbon dioxide to create space in which to work. Dr. Bessler struggled for 5 or 10 minutes to position the stapler properly, and then activated controls that opened it, like a miniature spaceship, inside Ms. Perez’s stomach.

A sail and curving wire emerged from the stapler to help push aside the folds of her stomach. Then Dr. Bessler turned on a vacuum pump to draw parts of the front and back walls of the stomach into the device to be stapled together.

Three rows of staples were needed, but the stapler holds only one row, so the whole apparatus had to be withdrawn, rinsed, reloaded, pushed back down Ms. Perez’s throat and painstakingly repositioned for each row. The Satiety consultants stood close by to coach, at one point warning Dr. Bessler that if he inflated Ms. Perez’s stomach too much, her first row of staples could pop. The surgery took three hours.

I'm not sure about this whole esophageal dilation. Doesn't that put patients at risk for something like Boerhaave's syndrome (esophageal rupture)? Just wondering. And even if it does work reasonably well, can you say 'turf war'? My guess is that gastroenterologists and bariatric surgeons are going to have at it if this becomes the next big thing in weight loss surgery.

FYI the term 'Toga' comes from transoral gastroplasty.

On a related note, I came across this title and found it funny:

Not only are the readers overweight, but now you're calling them dummies too?! Those poor people!

Update: For more information on bariatric surgery, check out Houston Weight Loss Surgery

On Becoming a General Surgeon

While I'm not going into general surgery, I think I still hold a romanticized notion of the general surgeon as some kind of master-of-the-universe figure who works smoothly and calmly with a high degree of precision. This, despite much evidence to the contrary. Even taking my experiences into account, I never thought the general surgery residency could be that bad. However, this interview on EMPhysician with a general surgeon (who eventually did a vascular fellowship) has me thinking otherwise:

How did you stay sane during training?
I didn't, actually. I just worked all the time. I gained 25 pounds, and developed varicose veins and plantar faciitis so painful, I took analgesics constantly. My blood pressure went up, and despite my best efforts, I could not eat healthy as a resident. I developed prediabetes, and basically ignored my physical needs altogether. It is a show of weakness to express the need for the requirement of basic human needs as a surgical resident. Going to the bathroom was a big deal, actually. My only saving grace was the fact that I was only in my mid/late 20s, and my body tolerated the abuse...abuse that would be difficult (perhaps impossible) to physically recover from for someone a bit older.

I had no hobbies, nor could I engage in any meaningful discussion with other people (outside of medicine), since I had no time to engage in the world activities and issues. I became very one dimensional, and my entire identity became "me, the surgeon."

Keep reading the post for a wide-ranging interview on the ups and downs of training to be a surgeon. Interesting stuff, wish I'd read it a long time ago.

Updated 2015-12-14

Michael E. DeBakey, 1908 - 2008

As you probably already know, Michael E. DeBakey passed away over the weekend. Many know of him as a pioneering surgeon, educator, and medical statesman. His accomplishments are widely known, and I cannot add much to that.

However, for my little part, I remember seeing Dr. DeBakey a few times, but my favorite memory was one Sunday morning a few weeks ago. My mother had convinced my father and I to check out the local Farmer's Market. While randomly browsing different produce, I spied a scooter out of the corner of my eye. Who else was it but Dr. DeBakey? Haha, seeing him there was a bit bizarre, but at the same time, it was nice knowing that at 99, he was still out and about. My little anecdote is probably trivial, but it reminds me that no matter who we are, we share a common humanity, whether we are a world-renowned heart surgeon... or just a medical student. Rest in peace, Dr. DeBakey.

Tips On Scrubbing In, Part 2

About a year ago, I wrote a basic introduction to scrubbing in. Having recently spent some more time in an OR, I figured it may be helpful to give a few more tips about what to do after you have scrubbed in.

• So you're scrubbed in. Now what? You want to approach the bed, but the room is now a mix of sterile and non-sterile areas. As you approach the bed, try your best to always face anything that is not sterile. If you have your back to something that is not sterile, you are more likely to bump into it.
• Move slowly. Never rush. Always keep your hands tucked into your body, between your nipples and navel.
• Once at the table, find a comfortable place to stand that affords you a good view. This can be hard sometimes.
  
• Once the patient is draped and sterile, you can relax a bit. Feel free to brace yourself against the patient's body with your hands. Just make sure that your hands are touching only the sterile drapes.
  
• When you are scrubbed in, you are going to be doing a lot of standing. Maintaining a good posture is key to avoiding back / leg pain later on. To do so, try to stand as straight and symmetrically as possible. Avoid favoring one leg over the other. Do not lock your knees, but rather bend them slightly in order to take stress off of your back. Also, stand with a wide stance to improve your balance.
  
• Find yourself nodding off? Make sure to look around / look away every few minutes. Try to bend and flex your legs periodically to keep them from hurting.
  
• Face itchy? Sweating? You CANNOT touch your face mask because it is not sterile. For the most part, you have to just deal with this. However, if it is a severe problem, you can always request the circulating nurse to dab your forehead or adjust your mask.
• Feeling faint? This happens occasionally. If you know it will pass momentarily, just stay calm and focus on your balance. However, if you really know you cannot hold your position, just let the attending (or first assist) know the problem, and ask to scrub out. It is better to scrub out than to fall into the field or onto the floor. Don't be a hero.

So yea, there you go. As interesting as the surgeries can be, there is always going to be a fair amount of standing around. Hopefully this will help make it a little more bearable.

Oops! In For A Leg Operation, Out With A ... ?

A German woman went in for a leg operation recently, but came out with something else entirely:

A German retiree is taking a hospital to court after she went in for a leg operation and got a new anus instead, the Daily Telegraph is reporting. The woman woke up to find she had been mixed up with another patient suffering from incontinence who was to have surgery on her sphincter. The clinic in Hochfranken, Bavaria, has since suspended the surgical team. Now the woman is planning to sue the hospital. She still needs the leg operation and is searching for another hospital to do it.

How does this even happen? Wouldn't two entirely different surgical teams perform these procedures? Wrong limb operations are one thing - it is easy to see how a patient who comes in with two diabetic feet might get a procedure on the wrong one, but this? How poorly prepared was the OR that no one had any idea whether they were operating on the right person / body part? I guess those OR "time outs" really do serve a purpose...

I guess I inadvertently took this week off for no particularly good reason, but I'll be back next week with new posts.

A Few Interesting Stories

Whew! Done with Step 1! I've enjoyed a few days off, but it's back to the wards tomorrow, specifically the psych wards. I don't have anything in particular to discuss today, so here's a smattering of links with interesting stories:

When a murderer becomes a medical student - a medical school in Stockholm is faced with a dilemma over what to do when a convicted murderer who has served his time is found to be in the student body.

Do statins really prolong a patient's life? - an interesting look at the issue of how to use a drug for a disease versus as prophylaxis.

Who really gets MRSA? - As reports of a new strain of MRSA among homosexual men appeared, the article notes another group that also has a high incidence of such infections.

Hoarseness on the political trail - Find out what the candidates do in their attempts to not lose their voice while being a "voice for the people."

Seven Common Medical Myths - Haha, I must admit, I have held at least 4 of these.

Does a surgeon's gender matter? - Wow, I never would have considered to research this, but it is something to ponder, especially in gender-based operations (ex. mastectomies, prostate surgery)

Atul Gawande and "Better" - A Medical Student's Review

As a med student, and one who had recently completed his surgery rotation, I feel I had a relatively unique perspective while reading this book, as compared to most readers. It was also interesting to read this book and gauge my reactions, relative to how I reacted when reading Gawande's prior book Complications. When I read Gawande's first book, I had not yet started medical school, and had at best, an educated lay person's background. I found the stories there intriguing and confirmed my romantic notions of medicine. This book mirrors my own internal evolution to a certain degree. Less romanticized, more practical, it discusses more of the everyday issues in medicine, ones that I see often as a student out on the wards. People do not wash hands as much as they should, the science of efficiency has not been applied to medicine, and the book takes us all to account for that. While medical technology has become remarkably efficient and high-tech, the actual delivery of medicine leaves much to be desired. Anyway, I digress.

The book reads very much like Complications. Gawande presents 12 separate essays about different aspects of healthcare, from the advances in obstetrics to the lack of investment in studying the provision of care to the doctors who are involved with executing prisoners who have been given the death penalty. Unlike Complications though, Gawande injects more of his own personal opinions after a more dispassionate presentation of each subject. The writing is sparse and clear, making it easy to read. Some of the chapters read almost like a medical Profiles in Courage

However, unlike Complications, this book did not leave me feeling as enthralled. Perhaps I have become jaded by medicine, or perhaps the topics of 'improving' medicine are simply not exciting. I think I liked Complications better simply because it dealt with more esoteric issues. While I agree with Gawande that the topics covered in Better are more important and can potentially affect many more people, the cases covered in Complications are simply more intriguing, such as the woman with necrotizing fascitis, or the reporter who sweat too much.

Overall: 9 out of 10 - a good engaging read that covers many important and relevant topics.

Updated 2015-12-06

Funny Colorectal Surgeon Song / Video With Lyrics

Since I am on my surgery core clerkship / rotation right now... Here's the Colorectal Surgeon Song by Bowser and Blue.

SONG: "Working Where The Sun Don't Shine" (The Colorectal Surgeon's Song)

We praise the colorectal surgeon
Misunderstood and much maligned
Slaving away in the heart of darkness
Working where the sun don't shine

Respect the colorectal surgeon
It's a calling few would crave
Lift up your hands and join us
Let's all do the finger wave

When it comes to spreading joy
There are many techniques
Some spread joy to the world
And others just spread cheeks
Some may think the cardiologist
Is their best friend
But the colorectal surgeon knows...
He'll get you in the end!

Why be a colorectal surgeon?
It's one of those mysterious things.
Is it because in that profession
There are always openings?

When I first met a colorectal surgeon
He did not quite understand;
I said, "Hey nice to meet you
But do you mind? We don't shake hands."

He sailed right through medical school
Because he was a whiz
Oh but he never thought of psychology
Though he read passages.
A doctor he wanted to be
For golf he loved to play,
But this is not quite what he meant...
By eighteen holes a day!

Praise the colorectal surgeon
Misunderstood and much maligned
Slaving away in the heart of darkness
Working where the sun don't shine!

A Funny Story During My Surgery Clerkship Rotation

Funny story I heard from a friend about a med student and the Chair of the Surgery Department here... we'll call him Dr. B

The student (let's call her Amy) is a 4th year med student rotating with Dr. B for a month on the general surgery service. Dr. B is known for being very touchy-feely with his patients and listening to their issues.. you know, the "softer" side of medicine. However, he's still a surgeon and definitely has a serious side.

The patient they are about to see on morning rounds has had many problems during her life. In addition to her surgery, she has many co-morbidities as well as stresses in her life. She has also been battling depression and weight issues. Today, her main concern is some kind of eye problem. Maybe a corneal abrasion or conjunctivitis, who knows. Dr. B and Amy proceed to talk to the patient and then perform a physical examination. Both carefully inspect the patient's eyes, conclude their visit, and quietly leave the room to discuss:

Dr. B: So, what did you think?
Amy: She has a lot going on...
Dr. B: I mean, what did you see in the patient's eyes?
Amy: Umm... sadness?

Dr. B: ...
Dr. B: What?! Go look in the patient's eyes again! What did you see IN the patient's eyes?!

Oh, Amy, sometimes you just can't win for trying =)

Rev 20200228

My Surgery Core Clerkship Experience

Surgery has been going pretty well. I only have 6 more days of general surgery! The time has really flown by. In the few weeks I've been here, I've seen several excisional breast biopsies, some laparoscopic Roux-en-Y gastric bypasses, some Port-A-Cath insertions/removals, a laparoscopic gastric banding procedure, and laparoscopic cholecystectomy. Not the broadest variety, I know, but it was good to see the same thing done several times to see the variety / scope of the technique. I also have gotten better at suturing up wounds and feel much more confident about my manual dexterity before starting surgery. It really is like tying knots on your shoelaces... slippery, bloody knots, but still.... same idea =) What I really should be doing is studying for the surgery shelf exam!

Some drink for thought: Does a "break the seal" phenomenon truly exist? I had never heard this phrase before, but OverMyMedBody has an interesting post about whether the first bathroom episode after drinking leads to subsequent ones.

Updated 20200228