• Michael Dworkin, MD

How to crush the surgery clerkship

Updated: Sep 28, 2018

Don't be intimidated. A few simple tips can help you get honors on your surgery clerkship!



How to prepare for your surgical clerkship


Like all clerkships, it helps to be prepared. One week before the rotation, email the resident you'll be with and briefly introduce yourself in one sentence. Ask where and when to meet them on the first day of the clerkship.


Here’s an example email you can send before your trauma surgery rotation:

Subject: Medical student starting on trauma next Thursday. Body: Hello, I'm an MS3 looking forward to starting on the trauma portion of my surgery clerkship next week on Thursday. I was wondering: what time and where should I meet you? Is there anything I should know before starting? Thanks! -Your Name

Before you start, read the first chapter of Surgical Recall. This will introduce you to basic terminology and surgical etiquette that will be helpful for the clerkship.


In addition, check out our blog post on the best clinical resources to help you crush your clerkships and USMLE Step 2 CK exam, as well as our post on how to use Anki during medical school.


Buy protein bars or quick snacks you can carry in your pockets before you begin your surgical rotation.



What to study early on during your clerkship


Doing the 150-200 UWorld Step 2 CK surgery questions during the first week of the rotation will be key. It's also important to complete the UWorld medicine GI, fluid and electrolytes, and renal questions early on during the clerkship. You'll also want to do the 400-500 Pestana questions during the first couple weeks.


For video resources, check out the OnlineMedEd surgery videos (general, subspecialty, and trauma) and the surgery shelf review from Emma Holliday.


If you’re on a surgical sub-specialty service such as cardiothoracic, make sure to skim the relevant chapters in Surgical Recall.


Before each operative case, review the relevant information for that operation from first aid, surgical recall, and if you have time, UpToDate. You can familiarize yourself with how the operation is performed, but this won’t be on your shelf or boards exams. Expect to be pimped on simple questions about anatomy, indications/criteria for operative intervention, and common post-op complications, during your time on wards or in the OR.



What to do on the first day of your clerkship


On your first day, ask your resident for advice on the rotation and have him/her show you what supplies to carry in your white coat. This will vary a lot depending on the service you're on. You could be carrying around a tub of wound supplies, or you could get by just carrying a pen and piece of paper. Most likely, it’d be prudent to carry wound the following items: stethoscope, pen-light, scissors, tape and 4x4s, and silk sutures to practice throwing knots. It really depends, so just ask your resident! I’d also recommend carrying a copy of Pestana’s vignettes for browsing during free time. Ask your resident where you can find a pack of silk sutures to practice your two handed knot technique. You can tie these to the loops of your scrub drawstring and practice them throughout the day when you have a free moment. Try to completely tie 10+ silk sutures each day and you'll impress your residents with your preparedness and initiative.


If you’ve never scrubbed in, ask your resident how to do this as you’re walking to the OR for your first operative case.



General tips for a successful surgical clerkship


You'll want to adjust your clinical technique to match that of surgeons.


First, be a good student. Meaning, be on time, clean and well groomed, professional with everyone you encounter, and willing to work hard and help out. Be straightforward and communicate clearly and deliberately with teammates. Don’t lie or make stuff up – if you didn’t examine something and are asked about it, just say you didn’t examine it. Know your patient very thoroughly – better than anyone on the team. Ask questions or for advice during downtime or when walking somewhere with your resident as opposed to when things are hectic.


If you’re told to go home for any reason, say “Ok, thanks! I’ll see you tomorrow!”.


If you are asked to do something you don’t know how to do, say you’ve never done it before and ask if you could be walked through it. For example, if you are asked to put on a sterile gloves/gown and haven’t done this before, say you’ve never done it before and ask for help. If you say you know how to do it when you don’t, you’ll probably immediately contaminate yourself and have to re-scrub.


Eat and go to the bathroom at every opportunity.


How to start a day on surgery


Go to the hospital early. How early? A rough rule of thumb is to arrive to the team workroom (20 minutes + 7 minutes per patient) early. This will give you time to pre-round on all of your patients.



How to pre-round on surgery patients


Pre-rounding on surgical patients is straightforward. Review vitals for each patient first. Then go to their rooms. Find their nurse and ask if there were any events overnight. Ask the nurse“Do you have Mrs. Smith in bed 35? Great! I’m Michael with the surgery team. How’d she do overnight?”. Go in into the room. Ask the patient how they’re doing. Always ask about chest pain, shortness of breath, nausea, vomiting, diarrhea, constipation, if their appetite is coming back, if they’re passing gas, if they’re going to the bathroom, and if they’re been getting up and out of bed. Ask any other relevant review of systems.


Be focused in your physical exam. Examine heart, lungs, and perform abdominal palpation for everyone (but only report relevant exam findings). Examine the area which was operated upon (e.g., examine the abdomen after abdominal surgeries, check pulses after vascular surgeries, etc). Directly examine the wound each day by removing the dressing, observing for signs of infection such as erythema, quality or presence of drainage from the wound or in any drains (Purulent? Serosanguineous?), gently pressing around the incision to feel for warmth and to see if any drainage can be expressed, etc. Note that a normal post op wound should appear clean, dry, and intact, without signs of infection, and that surgical drains normally drain pink colored (serosanguineous) fluid.



How to present a SOAP note to a surgical attending


If you’ve never presented a surgical SOAP, make sure ask practice first with a resident before delivering it to an attending.


Be brief in your presentation and make good eye contact. Make sure to include name, post-op day number, quick note on how the patient is doing, vitals, antibiotics if applicable, input and output (urine, drains, PO, fluids) if applicable, relevant changes in physical exam, new complaints or symptoms, and plan.


E.g., if you're trying to present a 50 year old female who is recovering well two days after an appendectomy, you could say either of the following:


Long: “Miss Smith is a 50 year old female now post op day 2 from a laparoscopic appendectomy for uncomplicated appendicitis who is recovering well. Her pain is controlled on oral analgesics, she is tolerating a regular diet with regular bowel function, and she is ambulatory. We will discharge her today with a one week course of opioids, patient instructions, and clinic follow up in 2 weeks.”


Short: “Miss x is post op day two from lap appy for uncomplicated appendicitis recovering well, pending discharge today.”


If you have a more complicated patient, your presentation will be longer, and should take the following format:


One liner (Miss X is a 50 year old female now post op day 2 from a laparoscopic appendectomy whose post operative course has been complicated by paralytic ileus.
Subjective (Overnight, she vomited three times. She is up and out of bed but has not had a bowel movement in three days.)
Objective (Vitals are Tcurrent, Tmax, HR ranged from low to high, BP ranged from low to high, RR ranged from low to high, O2 sat ranged from low to high. Ins and outs are normal saline at 100 cc/hour, urinary output 700 cc over the last 8 hours. Physical exam was significant for abdominal distension without peritoneal signs (no guarding, rebound tenderness, and rigidity).
Assessment/Plan. Overall, Mrs. Smith has ileus and is not progressing (vs stable, progressing as expected, or ready for discharge). Plan is to advance diet as tolerated and get an abdominal radiograph.


How to study for the surgery shelf


Redo your UWorld incorrect questions in surgery, and the above mentioned areas in medicine. Redo the Pestana questions. Re-watch the OnlineMedEd surgery videos. Re-watch the Emma Holliday Surgery Shelf review video. Do all of the NBME Clinical Science Mastery Series practice exams for surgery.



Take home points


Be prepared. Set yourself up for success. Do practice questions daily. Be a good student and follow the lead of your residents. Eat and go to the bathroom whenever you have a free moment.


Enjoy your surgery rotation!


For more information about our shelf exam and USMLE tutoring services, as well as the MedSchoolGurus Surgery Clerkship Anki Deck, check out medschoolgurus.com. To schedule a free 15 minute consultation session, visit medschoolgurus.com/contact.


Don't be intimidated. A few simple tips can help you crush your surgery clerkship.