• Clinical science

Surgery clerkship

Surgery overview

What is surgery?

  • Description
    • Surgery is a branch of medicine that evaluates and manages diseases and injuries that need to be treated with an operation.
    • The goal of surgery is to remove (e.g., appendectomy, resection of a tumor), repair (e.g., suturing a deep cut in the skin), or reconstruct (e.g., herniorrhaphy with a mesh graft) tissue lesions of any kind.
    • Surgery is a fast-paced specialty that requires very good collaboration of a multidisciplinary team (e.g., surgeons, anesthesiologists, operating room nurses, etc.) in order to function smoothly.
  • Subspecialties: Surgery is divided into a wide range of specialties and subspecialties, including:

What does a surgeon do?

  • Primary role: It is a surgeon's responsibility to establish the diagnosis and indication, perform the operation, and provide preoperative and postoperative care for the patient.
  • Daily life
    • A “typical day” varies greatly depending on specialty, presenting patients, daily assignments, and shift plan.
    • Surgeons spend a significant amount of time in the operating room (OR), where they perform procedures in a multidisciplinary team. Operations can be classified according to their urgency:
    • On the hospital wards, surgeons are primarily responsible for postoperative patients, who need to be monitored for proper healing and any potential complications.
    • In the outpatient clinic, surgeons see both preoperative patients (e.g., to establish the indication for operation) and postoperative follow-up patients.
    • Additionally, surgeons do consultations for other specialties.
  • Skills
    • For the management of surgical conditions, extensive knowledge of pathology and anatomy is particularly important.
    • Diagnoses are established using clinical skills (e.g., history and physical exam; H&P) and diagnostic tools (e.g., imaging and laboratory tests).
    • As surgical patients are often critically ill, surgeons need to be quick and confident at making important decisions concerning diagnostics and treatment.
    • During procedures, surgeons are trained to work with focus, endurance, and precision.
    • As a surgeon's work is often physically exhausting, stressful, and comes with long shifts, working as a surgeon requires a high amount of resilience.
  • Working as a general surgeon
    • The work of a general surgeon is typically very broad.
      • They treat acute and chronic conditions affecting almost every part of the body, including the gastrointestinal organs, the abdominal wall, the endocrine system, the breast, the skin, and soft tissue lesions.
      • They are also responsible for the management of a broad spectrum of trauma injuries.
      • General surgeons need to have a fundamental knowledge of other surgical specialties as well.
    • Typical procedures in general surgery include appendectomies, cholecystectomies, bowel resections, Nissen fundoplication, adhesion removal (for bowel obstruction), emergency laparotomies, breast biopsies, hemorrhoid surgery, and thyroid surgery.
  • Training and career options
    • Residency programs in general surgery last a minimum of 5 years, with many lasting 6 years to include a year of research.
    • Those who seek out further specialization can accomplish this via fellowships, e.g. in cardiothoracic surgery, plastic surgery, trauma surgery, vascular surgery, transplant surgery, or surgical oncology.
    • After completion of their training, surgeons can choose to pursue an academic career in the hospital or go into private practice.

Surgery clerkship overview

Clerkship structure

  • The typical length of the clerkship varies between 8–12 weeks, depending on the medical institution. It is usually divided up into:
    • 4–6 weeks in general surgery
    • 2–4 weeks in other surgical specialties (can be one or several)
  • The rotation can comprise the following:
    • Inpatient service
      • Surgical wards
      • Operating room
      • Possibly emergency medicine
    • Outpatient clinic

Clinical skills

  • Performing an H&P with a focus on common surgical conditions
  • Presenting patient cases and write notes
  • Gaining and displaying knowledge of the management of common surgical conditions, including diagnostic steps and treatment plans
  • Becoming familiar with OR etiquette
  • Learning how to scrub in and maintain sterile fields
  • Assisting in surgeries, which can include suturing, retracting, and guiding the laparoscopic camera
  • Understanding the indications, alternatives, and main steps of common surgical procedures

Daily schedule

This schedule is meant to provide a general idea of a typical day during your surgical clerkship, which will vary among different medical institutions and programs.

  • 04:45 a.m.: Arrive at the hospital and change into the appropriate attire (see “Dress code” under “Appropriate professional conduct” in the general clerkship article for more details).
  • 05:00 a.m.: Print out a patient list, take part in the sign-out, and start pre-rounding your patients.
  • 06:00 a.m.: Complete morning rounds.
  • 07:00 a.m.: During the rest of the day, you will primarily work in the OR or in the outpatient clinic.
    • OR: The first case usually begins at 07:30 a.m., and you should be present at least 15 minutes early.
    • Outpatient clinic: First patients are generally seen around 08:00 a.m.
  • 01:00 p.m.: lunch break
  • Afternoon rounds: If you're not busy in the OR, outpatient clinic, or with educational activities (see below), you will be expected to take part in afternoon rounds.
  • 06:00 p.m.: Sign-out and go home (or stay if you are on call).
  • Educational activities: take place throughout the week at different times of the day. You will be released from your other clinical tasks to be able to attend such activities.

Evaluation and grading

  • Varies among institutions but usually is pass/fail, and (typically) also high pass and honors. It consists of:
    • Clinical grade
    • Examination (usually shelf exam)
    • Possibly other assignments

AMBOSS study plan

  • AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:
    • Surgery: https://go.amboss.com/surgery [1]
    • ENT: https://go.amboss.com/ent [2]
    • Urology: https://go.amboss.com/urology [3]

Clinical tasks

Overview

  • Surgical clerkship students usually follow up to 3–5 patients at a time, ideally all the way from their initial presentation/admission, to the OR, and through to their recovery.
    • If you assisted in a procedure, you are most likely expected to follow that patient during the postoperative phase.
    • You will likely be asked to scrub in for patients that you admitted and provided preoperative care for.
  • Your clinical tasks will include:
  • In the subsections, we provide specific advice for clinical tasks in surgical departments. These tips should be seen as additional to the advice we give in the clinical tasks section of the “Clerkship guide.”

Objectives

  • After the surgery clerkship, students should be able to:
    • Obtain a full medical H&P for patients with acute and chronic surgical conditions.
    • Give patient presentations and write notes for newly admitted and continuing patients.
    • Gain and display scientific and clinical knowledge of common acute and chronic diseases that require surgical evaluation, which includes:
      • Formulating differential diagnoses and plan further diagnostic steps
      • Interpreting test results (e.g., laboratory values and radiology findings) in the context of common surgical pathologies
      • Discussing surgical treatment options and alternatives to surgical treatment
  • Furthermore, clerkship students should have:
    • Communication skills that show professionalism and empathy during conversations with patients and their families as well as colleagues and other medical staff
    • Cultural sensitivity and ethical behavior to address patients appropriately in life-changing situations (e.g., before procedures)
    • Strategies for self-assessments and self-directed learning in order to recognize knowledge gaps and consult reliable resources

As a clerkship student, you will be able to spend more time with your patients than when you're a resident. Enjoy this unique time and make the most out of it by truly getting to know your patients.

Pre-rounding

For general advice on pre-rounding, see the “Clerkship guide.”

  • General goal: In surgery, pre-rounding should focus on the system or area that was operated on. For example:
    • If the patient had debridement of a leg infection, you should be looking for information that pertains to the infection (e.g., vitals, CBC, condition of the wound, and microbiology).
    • If the patient had bowel surgery, do not forget to find out what kind of food they are eating and if they had bowel movements post-op.
    • See also postoperative complications in perioperative management.
  • When studying the chart
    • Always note the post-op day (POD).
    • Vitals: Check the temperature to monitor for postoperative fever.
    • Intake/output (I/O):
      • Intake:
        • Quality and quantity of food and drink intake
        • Route of nutrition (e.g., oral nutrition, total/partial parenteral nutrition)
        • Record “nothing by mouth” (NPO) status if the patient is not allowed to take in by mouth.
      • Output:
    • Tubes and lines: If the patient has an IV, central line, Foley catheter, or rectal tube, check how many days they have been in and if they need to be removed.
    • Laboratory studies: Be sure to check all lab values. In postoperative patients, pay special attention to signs of postoperative hemorrhage (e.g., a drop in Hb) or infection (e.g., increase in WBC).
    • Microbiology
      • Note any recorded infections and/or culture results (past and present).
      • If there was antibiotic sensitivity testing, record the findings.
      • Note any required measurement for infection prevention (e.g., need to use a mask, gown, and disposable stethoscope). See also isolation precautions.
    • Level of activity: post-op mobilization, ambulating
  • When seeing your patient
  • Other recommendations
    • If you have time, review the disease, complications, and especially the relevant anatomy of your patient so you can be ready for any questions from preceptors.
    • Be a team player: Do not forget to ask your fellow clerkship students if they need any help or ask them for help if you need it.

You should be the person who knows the most about your patients!

Rounding

For more general information on rounding, see the “Clerkship guide” article.

Before rounding

  • Complete your pre-rounding and prepare your notes and patient presentations.
  • Prepare a bag filled with wound care supplies.
    • Most surgical patients need a wound dressing change during rounds and supplies may not be in the room.
    • Carrying a bag with supplies will make rounds more efficient and the team will be grateful for your support.
    • Consider packing the following:
      • Wound dressings
        • Gauze sponges: Always have 4x4s (and some other sizes) on hand
        • Abdominal pads (ABD pads)
        • Gauze rolls
        • Nonwoven sponges
        • Alcohol pads
      • Wound bandages, including medical tape and/or adhesive bandage (e.g., Band-Aid®).
      • Mini-saline bottles: to moisten the 4x4s for packing
      • Syringes: Take a couple of different sizes, including syringes to flush nasogastric tubes.
      • Suture removal kits
      • Always carry a pair of cutting shears.

During rounding

  • Volunteer to do the undressing and dressing of wounds.
  • If any supplies, test results, lab reports, etc. are missing during rounds, volunteer to quickly get those.

After rounding

  • Finish writing your progress notes (if not yet completed).
  • If you do not have any other duties (e.g., assisting in the OR or lectures), offer your help wherever possible, for example:
    • Calling consult services
    • Entering orders
    • Updating the to-do list
  • Check incoming reports of lab results, microbiology, and pathology.
    • You should do this even if you work in the OR or the clinic during the day.
    • Inform your resident ASAP of all abnormalities and relevant findings, even from patients that you do not follow.
    • Do not talk to your patients about critical test results (especially pathology findings) before having talked to your resident.

When on a surgical service, you should always carry a pair of cutting shears.

Writing notes

Overview

See “Writing notes” in the “Clerkship guide” for more information.

In surgery, there are several different kinds of notes:

  • Admission notes: detailed notes for new patients including an extensive H&P
  • Progress notes: daily notes for the patients you follow on the wards, written in SOAP format (Subjective, Objective, Assessments, Plan)
  • Preoperative notes: written on the day before surgery (see also preoperative preparation)
  • Operation notes: written in the OR right after the procedure before the patient goes to the recovery room or PACU . Includes the indication, details about the procedure, and orders.
  • Postoperative note: written after postoperative rounding, no earlier than 6 hours after the surgery
  • Discharge note/hospital course: a summary of the patient's hospital stay, which should include:
    • Follow-up appointment (date and location) with provider (name, title, phone number)
    • Date of discharge (including the POD) and discharge destination
    • Brief outline of the hospital course, including:
      • What led to the hospitalization
      • Surgery date, complications, transfusions, antibiotics
      • Any inciting events and how they were resolved
      • Dates when lines, foleys, and tubes were removed
    • Discharge diagnosis
    • Admission diagnosis
    • Summarizing line (name, age, gender, comorbidities, surgery)

Examples

Example of a daily progress note

  • Subjective: No acute events O/N . Pt. noted no n/v , no d/c ; reports mild RUQ pain.
  • Objective:
    • VS :
      • T: 99°F
      • P: 84 bpm
      • BP: 124/82 mmHg
      • R: 19 rpm
    • Gen : NAD , resting comfortably in bed
    • CV : RRR , normal S1 and S2, no S3, S4 , murmurs, rubs, or gallops
    • Lungs: clear to auscultation bilaterally, no wheezes, rales, or rhonchi
    • Abd: soft, mild tenderness in RUQ, +BS x 4 quadrants, no masses palpable, no organomegaly; post-op wounds clean
    • Skin: no rashes, lesions, petechiae
    • Ext: 2+ pedal pulses bilaterally, no c/c/e
  • Assessment statement: The patient is a 42-year-old woman on postoperative day 1 for laparoscopic cholecystectomy. Improving well.
  • Plan: Advance diet. Follow-up with abdominal US . Monitor CBC, electrolytes, BUN, and creatinine daily.

Example of a preoperative note

Example of an operation note

  • Pre-op diagnosis: acute appendicitis
  • Post-op diagnosis: same
  • Procedure: laparoscopic appendectomy
  • Surgeon: [name of lead surgeon]
  • Assistants: [name of resident(s) and medical student(s)]
  • OP findings: no perforation, moderate intraabdominal adhesions
  • Anesthesia: GETA
  • EBL : 50 mL
  • UOP : 450 mL
  • IVF: 1500 mL Ringer's lactate
  • Specimens: appendix to pathology
  • Drains: none
  • Complications: none
  • Disposition: to recovery room, extubated, stable condition

Never forget to add the date, time, and signature to all of your notes and orders.

Your note is proof of your work. If it’s not in a note, it didn’t happen.

Presenting patients

See “Presenting patients” in the “Clerkship guide” for more details on what needs to be included when presenting patients. In general, your patient presentations should follow the SOAP format (Subjective, Objective, Assessments, Plan).

  • General advice for patient presentations in surgery
    • Keep it short and concise.
      • A surgical presentation is much more concise than a medical presentation and should not exceed 5–7 minutes. If it does, the attendings or chiefs may cut you off before you finish.
      • If you have trouble keeping your presentation short, think about what information is needed for today's decision making and cut the rest.
      • You still need to have detailed knowledge of your patient's current condition, medical history, and any changes in status even if you do not include those details in the presentation. Be prepared to receive additional questions after you've finished the initial presentation.
    • Always ask for feedback on your patient presentations to identify areas for improvement.

SOAP structure for patient presentations in surgery

For new patients

  • Subjective
    • Begin with a concise summary of the patient's clinical course up until this point.
      • Name, age, gender, comorbidities, why they are here, presenting symptoms
    • History of present illness: What event led to the hospitalization and why does the patient need surgery?
    • Past relevant history: This section of the presentation should paint a picture of whether or not this patient is physically fit for surgery.
      • Any contraindications to surgery
      • Comorbidities/current illnesses
      • Current drugs such as anticoagulants
      • Past surgical history
      • Bloodborne diseases
  • Objective and Assessment: same as for continuing patients (see below)
  • Plan
    • Should include the day and time surgery is planned.
    • Pre-op care (e.g., giving prophylactic antibiotics, NPO status, any IVs)
    • Post-op care plan, including the estimated time of how long the patient will stay in the hospital

For continuing patients

  • Subjective
    • Name, age, gender, comorbidities, post-op day, what surgery they received, why they are still here
      • For example, “Ms. Doe, a 65-year-old female patient with diabetes, post-op day 3 from a right hip replacement, is still feverish, with evidence of purulent wound drainage.”
    • Overnight events: what happened and how was it resolved
    • How they are doing today (same, improved, or not improved and why) and relevant findings of the review of systems
    • Any updates from consulting teams or nursing staff
  • Objective
    • Vitals
      • If stable and within normal limits: “The patient is afebrile, vitals are within normal limits.”
      • If unstable or there have been relevant changes: State current vital signs including whether they are up/down from a previous value (e.g., “Ms. Doe’s temperature is 103°F, up from 100°F overnight.”).
    • Physical exam
      • Pay particular attention to the system and area that was operated on.
      • Mention any changes in wound care and when the dressing was last changed.
      • Discuss changes in mental status.
    • Intake/output (I/Os):
      • Report overall intake and output, urine output, and number of bowel movements.
        • For example, “Ms. Doe had 1.9 L in and 2.1 L out, urine output was 75 mL/kg/hr, and she had no bowel movements since yesterday but is passing gas.”
      • Mention any tubes or lines the patient has and how long they’ve had them.
    • Relevant laboratory studies
      • Report lab values with significant changes.
        • For example, “Hemoglobin is up to 9 g/dL from 7 g/dL since yesterday.”
      • Report any labs that are outside reference values.
      • If there are no relevant changes, you can state the following:
        • “No changes in labs since yesterday.”
        • “Labs are within normal limits.”
    • Medication
      • Mention changes in current medication (both drug type and dosages) and side effects.
      • Report how often PRN medications were administered.
  • Assessment
    • Give a short summary that focuses on the working diagnosis and the condition dynamic (i.e., whether it is improving, worsening, or stable).
    • Mention differential diagnoses of any abnormal findings, including possible postoperative complications.
  • Plan
    • Sum up the plan for the day.
    • Report what needs to be done in order to discharge the patient.
    • Surgical patients need the following to be discharged:
      • Vitals stable and within normal limits
      • Bowel movements
      • Ambulating
      • No lines, catheters, or tubes
      • A place to be discharged to

Surgical patient presentations should be short and concise.

Placing tentative orders

For more information on how to place orders (e.g., for medication, imaging, or consults), see “Placing tentative orders” in the “Clerkship guide.”

Working in the outpatient clinic

The outpatient time during your surgery clerkship typically involves evaluating both pre-op and post-op patients.

  • Pre-op patients
  • Post-op follow-up patients
    • Familiarize yourself with the procedure that was performed and any complications that need to be addressed.
    • Do not forget to check the wounds.
    • As an example, a follow-up appointment for a patient who has had a simple cholecystectomy should include the following:
      • Check the incisions to see how they are healing.
      • Ask the patient about signs and symptoms of infection (fever, redness, drainage) and about abdominal pain.
      • Discuss the possibility of diarrhea after consuming fatty foods now that they do not have a gallbladder.

Call duty

For more information on responsibilities when being on call and typical call schedules, see “Call duty” in the “Clerkship guide.”

Clinical skills (H&P)

History taking

  • For general information on history taking, see the article on medical history.
  • Some points to keep in mind for surgical patients:
    • Always ask about previous surgeries.
    • Allergies: drug allergies and allergies to iodine (used for sterilization), latex (contained in gloves), and other materials the patient might come in contact with during or after a procedure (e.g., allergies to metals relevant for implants)
    • Medication: Do not forget to ask about anticoagulants.
    • Ask about anything that could lead to complications during anesthesia, e.g.:
      • Cardiovascular and pulmonary diseases
      • Smoking and alcohol
    • If the patient needs emergency surgery: Ask when they had their last meal and which medication(s) they took today.
    • Ensure that the patient is authorized to give their consent for procedures (see also informed consent).

Physical examination

Surgical tasks and skills

Overview

  • The surgery clerkship is a hands-on rotation during which you will obtain vital skills that are useful across multiple disciplines.
  • Your surgical tasks will include:
    • Working in the OR
      • Supporting the OR team with preparing a patient for surgery
      • Assisting in surgeries
    • Performing other tasks specific to surgery (e.g., removing drains and chest tubes, or taking part in a trauma code)

Objectives

  • After the surgery clerkship, a student should feel confident in the following surgical skills:
    • Actively participating in the preparation of patients before their procedure
    • Respecting the OR etiquette
    • Scrubbing in and maintaining sterile fields
    • Assisting in surgeries, which can include suturing, retracting, and guiding the laparoscopic camera
    • Performing minor invasive procedures, such as Foley catheter insertion or placing nasogastric tubes
    • Changing wound dressings
  • Furthermore, a student should gain and display knowledge of:
    • The indications, alternatives, and main steps of common surgical procedures
    • How to assess a patient's fitness for surgery and risk factors
    • Important steps of preoperative and postoperative management
    • How to recognize intraoperative and postoperative complications and be familiar with treatment options

Working in the OR

General tips

  • Come prepared
    • Plan ahead: Make a note of the planned cases for the next day, and talk to your fellow students to make sure every patient is covered by (at least) one medical student.
      • For in-house patients, you should write a pre-op note on the evening before the procedure.
      • Read about the cases you signed up for.
    • Study anatomy: Surgeons will not expect you to know how to do the procedure, or to be able to name all of the tools. But they do expect you to know your anatomy from skin to bone. The majority of questions from attendings/residents in the OR will be on anatomy.
    • Read up on your patient
      • Know relevant history and labs (e.g., know if they have diabetes, an endocrine issue, or a blood disorder).
      • Review their chart and make sure they have an updated H&P. For same-day admissions, you might have to do the H&P on the morning of the procedure.
    • Watch a short Youtube video about the procedure you will see. This will make you feel more confident during the surgery and it will be easier for you to anticipate the next steps.
    • Make sure your fingernails are short and remove nail polish or artificial fingernails.
  • Do not neglect your basic needs
    • Go to the bathroom and use it before a case begins, even if you think you do not have to. Complications can occur during any standard procedure and turn a one-hour planned surgery into a 6-hour sprint.
    • Eat and drink something before going into the OR to avoid dizziness or fainting.
  • Know the team setup
    • The OR nurse/circulating nurse has broad tasks that include:
      • Preparing the OR and the patient for the surgery
      • Working outside of the sterile field (e.g., handing tools to the scrub nurse or taking care of specimens)
      • Documenting all aspects of the surgery (e.g., times, names of involved staff, and instruments that were used)
      • Conducting the turning over of the operation room between two procedures
    • Surgical technician : sets up and guards the sterile fields in the OR, hands instruments to the surgeons
    • Anesthesiologist: conducts the anesthesia, is involved in the management of complications (e.g., transfusions in the case of heavy bleeding)
    • CRNA (certified registered nurse anesthetist): involved in anything related to anesthesia, e.g., administering drugs, placing peripheral lines, and assisting with intubation
    • Surgeons
      • Lead surgeon: usually attendings
      • Assistants: usually residents and/or medical students. Most procedures require 1–3 assistants.
    • Other staff/people working in the OR: surgical assistants, physician assistants, nurse practitioners, medical device company representatives (new implants or operating tools that are rarely used), housekeeping staff
  • Talk to the head OR nurse
    • Getting along with the head OR nurse is essential if you work in the OR on a regular basis. Make sure to be polite and respectful.
    • Ask about the general organizational structure and workflow in the OR.
    • Ask about the attendings and what they do/do not like. This will help in anticipating their needs and working within their expectations.
    • Ask for some general information, e.g., where the following items are located: patient transfer board, warm blankets, new gowns, and oxygen tanks. This allows you to take a proactive approach towards prepping a patient for surgery.

Tasks before a procedure begins

  • Talk to your patient in the pre-op area.
    • Explain your role and reassure them that you will do your best to make them feel comfortable.
    • Let them confirm the side that will be operated on (if applicable).
    • Only answer questions you are authorized to answer. Defer all other questions to qualified team members.
    • Never make any promises (or lie) to the patient, but you can reassure them by telling them that they are in good hands.
    • Tip: Let the patient see how you look in a mask so they will be able to recognize a familiar face in the OR.
  • Arrive early: Go to the OR at least 15 minutes before the case begins to help with preparations.
    • Always keep a close eye on the OR board as scheduled surgeries will not always start at the time originally planned.
    • If you finish a case sooner than expected and the next patient is covered by a different student, let them know, so that they won't be late.
  • In the changing room
    • Change into your surgical scrubs if you haven't already.
    • Get a mask, surgical cap, surgical shoe covers, and disposable protective eyewear.
    • Remove all watches and jewelry (including wedding rings).
    • Wash your hands with normal soap before entering the OR area.
    • Put your phone on silent (your phone should be nonexistent in the OR).
  • When you walk into the OR
    • Most important: Say hello, introduce yourself, and briefly state your role.
    • Ask if there is a board to write your name on and if so, also note your year in medical school.
    • Immediately notice where the sterile zones are and keep an appropriate distance.
  • Interact with the surgical technician (also called a “surg tech” or “scrub nurse”)
    • Tell them you will be scrubbing in and if you can go get gloves and gowns.
    • Use sterile technique to open the gown and glove package; the surg tech, if assisting you, will remove the gown and gloves for you.
    • Ask if there is anything you can help with. The scrub nurse can be your biggest advocate and informant as long as you are polite and respectful.
  • When the patient comes in
    • Go get warm blankets.
    • Help to transfer the patient from the bed to the operating table.
    • Once the patient has been transferred to the table, take off the cold blankets and put on the warm blankets.
    • Help the nurse put on the IPC (intermittent pneumatic compression) leg covers, plug in the machine, and turn it on.
    • After the patient has been successfully intubated, take the blankets and gown off of the patient.
    • Additional skills you can learn here:
      • Intubating the patient: Interacting with the anesthesiologist(s) is not only allowed but encouraged.
      • Inserting the Foley catheter: If you know a procedure calls for Foley insertion, volunteer to do it. If you do not know how it works yet, show your interest in learning it.
      • Sterilizing the field: the process of rubbing the iodine solution on the body part or area that will be operated on
        • After you have seen a few patients get sterilized for surgery ask your lead surgeon if you could do it yourself.
        • The surg tech or OR nurse will walk you through it and you must do it exactly how they tell you.

Scrubbing in and gowning

See pre-surgical infection prevention measures for detailed instructions for scrubbing in, gowning, and gloving.

  • Before scrubbing in
    • Remember to put on your protective eyewear and make sure it fits comfortably.
    • Take any larger objects (e.g., phone, pocketbooks) out of your scrub pockets.
    • Secure your hair tightly under your cap to ensure it doesn't fall out during surgery.
    • Open your sterile gown and glove packages but do not don them yet.
  • Scrubbing in
    • The goal of scrubbing is to decrease the number of pathogens in both transient and resident skin flora.
    • There are many different surgical scrubbing techniques and each hospital has its own strict protocol for scrubbing in.
    • Before you begin, wash your hands with soap and use the nail pick (contained in the brush package) under the running water to thoroughly clean under your fingernails.
    • With the exception of cleaning the nails, only the soft side of the scrub brush should be used for scrubbing.
    • Some hospitals prefer a brush-less technique.
    • When scrubbing in, always keep your hands at a level above your elbows. Begin washing at the fingers and work your way down to the elbows.
    • If you touch anything (e.g., the water tap or the sink) during the scrubbing procedure or before gowning, you have to start over.
    • After you're done scrubbing in, use a sterile disposable towel (usually contained in the gown package) to dry your hands.
  • Gowning and gloving
    • If you finish scrubbing in at the same time as the surgeon(s), step back so that they can get dressed before you.
    • Usually, the scrub nurse (or another qualified nurse or assistant in the room) will help you get into your gown and gloves.
    • You will often wear two pairs of gloves (ask the OR nurse if you are not sure when this is needed).
  • Maintain sterile technique: Once you are fully dressed, remember to maintain sterile technique.
    • Never let your hands go below your waist, above your nipples, or on your back as these areas are considered unsterile.
    • If you do not know what to do with your hands, clasp them, with your fingers interlaced.
    • Only touch what the surgeon or surg tech allows you to.

During a procedure

General rules in the OR (“OR etiquette”)

  • Maintain an appropriate distance to anything that is sterile (usually indicated by the color blue).
  • Say “please” and “thank you” and be respectful to all OR staff members.
  • Stay active before and after procedures by offering your help and avoid standing in the way.
  • Never take instruments or equipment from the surg tech’s table without explicit permission.
  • Remember, under no circumstances is it acceptable to talk poorly about a patient, even when they are under general anesthesia.
  • The first assistant stands opposite to the lead surgeon. You will likely stand next to the lead surgeon.
  • Be careful not to lean on the patient, as you could potentially hurt them.
  • Avoid leaning in too close to the open surgical site, as you might compromise the sterile field.
  • Look before you move.
  • If you accidentally touched something outside of the sterile field, announce it and go rescrub.
    • This point is very important because you could introduce contamination to the patient if you do not rescrub.
    • Many medical students fear the repercussions of breaking sterile technique. Remember to act appropriately in such situations; the consequences will be far worse if you remain silent and hope that nobody saw your mistake.
  • If you drop something, apologize and leave it there. Do not try to pick it up or you will have to rescrub.
  • If you have to sneeze, let the team know (so they can take over your retractors, etc.), step away from the table, and turn around. Do not let your hands come anywhere near your mask.
  • Asking questions:
    • Ask for permission to talk before asking your actual question. The surgeon will not have the patience to answer questions if they're performing a critical step in a procedure that requires their full attention and concentration.
    • You can impress the surgeon by asking thoughtful questions that reflect your interest in the case, but do not ask questions you already know the answers to.

Tasks for medical students during procedures

  • Retracting: Make sure the surgeon has a good view of the operating field.
  • Suction: Clear the surgeon's view of structures.
  • Clamping: The surgeon will hold the structure that he wants to be clamped. Clamps (as well as scissors and needle-drivers) are held with the thumb and the fourth finger.
  • Cutting sutures: Make sure you ask the surgeon how short they want it.
    • If short: Take the scissors, open them, and place one of the open blades 2–3 inches above the knot on the suture, but do not make the cut yet. Slide the scissors down the suture until it touches the knot. Rotate your hand laterally to 45°, and then proceed to make the cut. With this technique, you cut the suture short without cutting the knot by accident.
  • Handling the camera during laparoscopic procedures: If you're handling the camera well, the surgeon might let you perform little tasks using the laparoscopic operating instruments.
  • Preparing mesh implants: This requires you to make sutures around the mesh for the surgeon to secure it in the patient.
  • Making the first cut: Some surgeons will allow medical students to make the first cut in surgery.
  • Passing surgical instruments: Most of the time, the surg tech will hand over the instruments.
    • Sometimes the surg tech will give you the instruments in advance, and you'll need to pass them on to the surgeon once he requests them.
    • Pass the instruments with the handles firmly placed in the middle of the surgeon's palm. Do not let go until the surgeon grasps the handle and takes it from you.
  • Suturing and closing: Medical students are often allowed to do epidermal closures.
    • Practice different stitching techniques, as well as one and two-handed knots, and instrument tying.
    • When suturing, stand up straight and try not to bend over. Do not take short cuts when placing epidermal sutures.
    • If the surgeons are happy with your epidermal sutures, they will eventually let you do subcutaneous closures as well.
    • You may also be allowed to perform several other closing techniques, e.g.:
      • Attaching (securing) drains to the skin
      • Closing surgical wounds using adhesive glue, staple guns, or surgical tape
      • Performing vacuum-assisted closures
      • Packing and creating seals to continue surgery on another day
  • Examples of subspecialty tasks
    • Orthopedic surgery: drilling into bone, inserting/taking out a screw, dislocating/relocating a hip, holding the leg, making traction for a body part, holding a body part still for the surgeon
    • Surgical oncology: removing the tumor, performing paracentesis, seeing the pathologists process cancerous tissues, seeing live diagnosis by pathologists mid-surgery
    • General surgery: helping out with debridement (scrubbing out a patient’s wound, which can include the entire abdominal cavity)
  • First assistant: Sometimes, you will be the first assistant in a surgical case (typically when there is no resident available). In this case, your role will be a lot more active and you will get to complete more advanced tasks, such as putting in a mesh or doing an entire closure by yourself.

Additional tips

  • If you get injured from a needle or another sharp instrument you should immediately notify the attending and take appropriate steps for infection prevention. See needlestick injuries for more information.
  • Before your first shift in the OR, review video tutorials on scrubbing in, gowning, and gloving.
  • If it is your first time assisting in a procedure and you feel insecure, do not hesitate to say so and ask for guidance.
  • As a general rule, you should only do what is requested of you. This can be an active (e.g., suction) or a passive motion (e.g., retracting), or both at the same time.
  • Try to anticipate the leading surgeon's next move and always pay attention to their requests (which are only mumbled sometimes).
  • Keep in mind that everything you do (and do not do) should aim at the best possible operating conditions for the lead surgeon.
  • Do not underestimate the importance of “easy tasks” like retracting and suction. Only when the surgeon sees that you can do these well, will you be allowed to assist with more advanced tasks.
  • If you have trouble with trembling hands, rest your operating hand or forearm on your other hand/forearm (or on the patient but only with very light pressure).
  • If you feel dizzy or faint, ask if you can step away from the table and sit down. Maybe even unscrub and get a glass of water and something to eat.
  • Practice using instruments (e.g., clamps and scissors) with both hands.
  • When you practice your knot-tying skills outside of the OR (which you should do), wear a pair of latex gloves to get a better feeling for real operating conditions.
  • If you know that you will have to leave the OR before the end of a procedure (e.g., to attend a lecture), let the attending know in advance and mention it again a couple of minutes before you actually have to leave the operating room.

If you get a needlestick injury, you should immediately inform your attending.

Tasks after a procedure

  • Help with cleaning up and transferring the patient to their bed.
  • Follow your patient to the recovery room or PACU.
  • Write an operation note.
  • Ask the scrub nurse for unused ties that you can use to practice your knots.

Good teamwork is particularly important when working in the OR.

Other surgical tasks

  • Wound management
    • Wound dressing changes (see “Rounding” above)
    • Removal of sutures or staples
  • Lines and drains
    • Inserting central lines: This is something you can do when rounding in a surgical ICU and sometimes in the OR (see also central venous access).
    • Putting in or taking out chest tubes
    • Taking out drains
    • Inserting nasogastric tubes
  • Tasks in trauma surgery
    • Trauma codes
      • At the beginning of your clerkship, familiarize yourself with your hospital's trauma codes and the relevant criteria associated with each.
      • Understand how trauma patients are managed and what the role of each member of the ER staff is.
      • As a medical student, your primary role will be to cut the patient's clothes off and assist with moving them so the primary survey can be completed.
      • Know where the gowns are so when the primary survey has been completed, the patient can be properly draped before the radiology team enters.
    • Second surveys
      • Second surveys are a more thorough physical exam after life-threatening complications have been addressed.
      • It is a comprehensive physical exam from head to toe.
      • Your resident should have a template on the EMR to help guide you through it.
  • Organ procurement runs
    • If your hospital does transplantations, you might have the chance to assist in an organ procurement run via ambulance or even helicopter/airplane.
    • To ensure you're able to get involved in a procurement run, it's best to proactively approach the responsible person(s) beforehand and let them know to page you.

Appropriate professional conduct

Top 10 surgery topics

  1. Cholelithiasis, choledocholithiasis, cholecystitis, and cholangitis
  2. Bowel obstruction
  3. Acute appendicitis
  4. Diverticular disease
  5. Acute abdomen
  6. Colorectal cancer
  7. Gastric cancer
  8. Inguinal hernias
  9. Skin and soft tissue infections
  10. Thyroid cancer

Evaluation and grading

  • Varies among clerkship programs and institutions but may include pass/fail, and typically also high pass and honors
  • Involves two or more components:
    • Clinical grade: consists of an evaluation of clinical performance by preceptors (attendings, residents, and interns) and possibly other tasks such as patient presentations, observed H&P, patient write-ups, admission orders, and clinical logs
    • Examination: consists of shelf exam (NBME® for MD students, or NBOME® COMAT for DO students) and/or sometimes in-house exams
    • Various assignments: Some institutions have additional didactic work to be completed throughout the rotation. This may include quizzes, reading logs, and patient logs.
  • See evaluation and grading in the “Clerkship guide” for more details.

Impress your preceptor

See clinical evaluation: how to impress your preceptors in the “Clerkship guide” for more information.

Tips to impress your preceptor in surgery

  • Show up 20 minutes early to everything.
  • Be prepared for the surgery. Look at the list of surgeries the day before they occur. Go home and study the anatomy, pathology, and physiology of the surgery so you are ready to get quizzed.
  • Remember to be humble and leave any preconceived notions behind when working in the OR.
  • Attendings rely heavily on their OR team, which is usually handpicked by each surgeon. When writing clinical evaluations, attendings often ask for feedback on medical students from the OR team.
  • Try your best to get along with the nurses and other staff. Most scrub nurses are like the surgeon's right hand; if you impress the scrub nurse, chances are the surgeon will like you. An OR nurse or surgical technician can also be a deciding factor for a letter of recommendation.
  • Practice your suture technique. This is a great way to impress preceptors with your skills.
  • Show enthusiasm. If your attending asks if you want to scrub in on a case, they expect you to feel honored and you should always accept.
  • See yourself as an integral member of the surgical team.

You are not there to compete against others but to help patients. You will shine the brightest when you show your commitment to the patient and eagerness to learn.

Preparing for questions from attendings (also sometimes referred to as quizzing or “pimping”)

For general advice, see preparing for questions from attendings in the “Clerkship guide.”

  • Keep in mind that in surgery, quizzing will occur both on the wards and in the OR.
  • Before you leave the hospital, have a look at the OR board for the next day, so you can review these procedures ahead of time.
  • Surgeons often ask questions about anatomy, especially during operations when these structures are easily visible.
  • Short and concise answers are generally preferable.
  • See the “Top 10 surgery topics” section below.

The shelf exam

For general advice, see “Exams: what to expect” in the “Clerkship guide.”

  • The surgery shelf exam is a case-based exam that tests students on their ability to diagnose and manage surgical patients, including determining whether a patient needs surgery. It is typically taken at the end of the surgery clerkship.
  • The exam is administered at authorized testing locations (like Prometric test centers on and off campus) and is formatted as an online test.

Topics of the surgery shelf exam

Tips for the surgery shelf exam

  • For general advice on studying during clerkships, see “Studying effectively during clerkships” in the “Clerkship guide.”
  • Studying tips
    • Using AMBOSS
      • Besides its comprehensive library with hundreds of surgery-related articles, you will also get access to more than 750 questions that will help you prepare for your surgery shelf exam.
      • We also have curated study plans for internal medicine and subspecialties. See “AMBOSS study plans” below.
    • When in the OR, there are many times where you are waiting for a case to be prepped and ready for the surgery. If your preceptor does not require your help during this process, then use this opportunity to study.
    • The OR lounge is a great place to review pocket-sized study resources or the AMBOSS app. This allows you to make the most out of a somewhat unpredictable schedule and study in shorter, more frequent sessions.
  • Focus on how to quickly discern whether or not a patient needs an operation.
  • Understand the presentation, workup, diagnosis, and management of high-yield surgical topics.
  • For trauma patients, always remember your ABC’s: airway, breathing, and circulation.
  • If in doubt, go with your gut (within reason). You have a limited amount of time for the exam, and you won’t want to waste a second of it overthinking the details.
  • Study in scrubs: use what you learn in the hospital to guide your studying when you get home.
  • There is a significant overlap between the internal medicine (IM) and surgery shelf exams. Taking IM before surgery (if possible) could help boost your score.

AMBOSS study plans

AMBOSS has created study plans with recommended articles and questions for all clerkships and some subspecialties, including:

  • Surgery: https://go.amboss.com/surgery [1]
  • ENT: https://go.amboss.com/ent [2]
  • Urology: https://go.amboss.com/urology [3]

Resources

You can use AMBOSS both as a clinical companion on the wards and as a reliable study guide for your surgery shelf exam.

  • Access hundreds of surgery-specific articles in the knowledge library when you’re with patients or rounding with your team.
  • Practice for the shelf exam with more than 750 questions in the Qbank.
  • See “AMBOSS study plans” above.

There is a list of useful general resources for all clerkships in the “Clerkship guide.” Here are some further resources specific to surgery:

Reading material

  • Review books
    • Dr. Pestana's Surgical Notes [5]
    • Surgical Recall [6]
  • Guidelines published by specialty associations
    • The American College of Surgeons [7]
    • The American Society of Colon and Rectal surgeons
    • The American Cancer Society
    • The American Association of Neurological Surgeons
    • The American Association of Oral and Maxillofacial Surgeons
    • The American Board of Orthopaedic Surgery
    • The American Board of Otolaryngology
    • The American Pediatric Surgical Association
    • The American Society of Plastic Surgeons
    • The American Urological Association
    • The American Association for Thoracic Surgery
    • The Society for Vascular Surgery
  • Journals
    • The Journal of the American College of Surgeons
    • JAMA Surgery
    • Annals of Surgery
    • Archives of Surgery
    • Surgical Clinics of North America

Videos

  • YouTube: Search for procedures and surgical techniques such as suturing and knot tying.

Preparing for residency applications

  • See the article “Residency applications” for general information (including about letters of recommendation and research opportunities).
  • Additional tips if you consider specializing in surgery:
    • See American College of Surgeons: “So you want to be a surgeon.” [8]
    • Participate in advanced surgery clerkships and sub-internship opportunities in surgical subspecialties when feasible.
last updated 07/08/2020
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