For non-surgeons, the surgical rotations are always a bit of a trial. The surgical/medical divide is real so spending months on the other side of it can be a challenge. I guess clerkship's worse for the surgical gunners though - I only spend 3 months or so in surgery, but they spend almost all of clerkship out of it!
Anyway, continuing on with my series, here is what I liked and didn't like about my surgical rotations.
1) I get bored during operations
I encourage everyone to step into an OR or two early in pre-clerkship. Surgery, despite it's terrible job market and long hours, is still very competitive overall and it's worth knowing whether you may need to push for it as a potential residency option. My guideline is that when you step into the OR, unless it's something obscure and weird, you have to love what's going on. Being interested isn't enough - the road to becoming a surgeon is too long and arduous to sustain mere interest, you need to be enraptured by the whole thing.
The first time I stepped into the OR I was, at best, mildly intrigued. I knew at that stage that I wasn't a surgeon. Now, after months in there, I'm downright bored. I understand the basics of what goes in the OR and the details don't interest me in the slightest. Definitely not a surgeon.
2) Love the surgical attitude towards medicine
When it comes to medical management of patients, nothing beats the typical surgeon attitude - they're clear on what they do and what they don't do. What they do they do quickly and efficiently. No debating things back-and-forth for half an hour - a decision gets made that's that. That does mean some things they probably could/should handle they pass off to others and, in an ideal world, physicians would take responsibility for the totality of their patients, not just the parts they want to manage. However, the alternative I've seen has been physicians trying to do too much and stepping on each others' toes, creating confusion for patients and providers alike. Again, in an ideal world, stronger communication between physicians would occur to address this problem, but clearly defined roles can be an enormous benefit whether proper communication occurs or not.
3) Don't love the surgical attitude towards people
Surgeons can be judgmental. Really judgmental. Of patients, of physicians (especially non-surgeons), of other healthcare staff. Don't get me wrong, physicians in general are fairly judgmental as a group, but surgeons seemed to be more blatant about it. Some of the attitudes and statements bordered on unprofessional. As with most places, it was a distinct minority who were the main culprits in these activities - in fact, some of the best staff and residents I've worked with were on my surgery block. However, that minority was entrenched enough and vocal enough that they seemed to influence the overall culture. A physician or resident who was needlessly harsh on a patient, subordinate or colleague was often encouraged or at least tolerated. On the opposite side, kindness and understanding were occasionally mocked. I have no doubt that these were meant as jokes without maliciousness, but that seems a distinction without a difference - in either case, a negative attitude towards others was fostered.
4) Long hours, little sympathy
It goes without saying, but hours in surgical specialties are LONG. 10 hours at the hospital is a short day. 12 is typical. 13 is within the normal range. All told, on average and after considering things like travelling to the hospital or doing the bare minimum to perform my clinical duties, I had between 10 and 11 hours of my own time for non-call days. That's as little as 10 hours to eat, sleep, study, exercise, spend time with my SO and my dog, and pretend to be a normal human being. I mostly ended up shorting myself on sleep and exercise to preserve a tiny amount of time with my SO and to study. It was sheer exhaustion and I feel like it's going to take a long time to recover from this level of fatigue.
Of course, as a student, you get zero sympathy. Residents work even longer hours, with more responsibility, and have been doing it for years. Staff went through the whole process and still tend to work long hours deep into their careers. Moreover, it wasn't too long ago when students had it much, much worse. Still, better doesn't equal good, and we're still a long, long way away from having anything resembling reasonable working hours in surgery.
5) Camaraderie
Surgical departments are small. There aren't that many staff and the number of residents coming through each year is considered large if it hits half a dozen. Many surgical residency programs take only one or two each year. Over the 5+ years, it does become obvious that the staff and residents end up knowing each other well. The residents especially seem to understand that as hard as it is to get through their residency, they're in it together. The best way I can describe surgery is like being in a frat, with both the good and the bad that come with it. The familial, laid back atmosphere was definitely a positive, and in sharp contrast to some larger specialties that weren't nearly as closely knit.
6) The Happiness Test
Are surgeons happy? Nope.
Ok, ok, it's not that clear cut. Many seem to really enjoy their work, especially when they're at the staff level and in the operating room. Yet, by and large, I didn't see many overly happy people. Frustration and exasperation were common occurrences. I wasn't the only tired person there, it was obvious on the faces of some residents and staff. They were determined and resilient, but it's hard to call someone happy when they're still in the middle of the fight.
Showing posts with label surgery. Show all posts
Showing posts with label surgery. Show all posts
Saturday, 27 August 2016
Monday, 11 July 2016
Surgery in the Summer
Surgery in the summer is a bit of a different beast compared to surgery in the rest of the year.
There's less OR time, more people are on vacation, the sun is out most of the day, there's no snow. Days are a bit shorter since there are fewer patients to round on. Even when the hours are pretty long, the warm weather and sunshine somewhat counter-acts the never-ending exhaustion. The balance of responsibilities shifts away from being in the OR to doing consults or clinics.
The downside is that experiences are a bit limited. There's not always enough ORs, consults, or clinics to go around. Surgeries that do happen tend more towards the emergent or urgent, as elective procedures get deferred to the fall when OR time increases.
For those with no interest in becoming a surgeon - like me - it's a pretty good deal. There's a decent amount of time for studying and less time standing in an OR seeing procedures I'll never participate in again. A bit more learning for my long-term career interests, less of a service component. Had some decent impromptu teaching as well, tailored to my career interests. For those who are seriously considering surgery, it's a time to avoid. Too few opportunities to shine or get hands-on learning with direct relevance to a career in the OR. Lots of sharing of experiences with other students, given limited work to do. Physicians are on vacation all the time, meaning few chances to spend more than a week with a single physician, and less time to impress any one of them.
Hard to do much about this when your clerkship schedule is already set, as it is for most people starting their 3rd year in September, but something for me to keep in mind when it comes to planning electives and/or setting up rotations for my residency. To survive surgical rotations, pick the slow times; to thrive, busier times are better. As a non-surgeon, I'm happy with survival.
There's less OR time, more people are on vacation, the sun is out most of the day, there's no snow. Days are a bit shorter since there are fewer patients to round on. Even when the hours are pretty long, the warm weather and sunshine somewhat counter-acts the never-ending exhaustion. The balance of responsibilities shifts away from being in the OR to doing consults or clinics.
The downside is that experiences are a bit limited. There's not always enough ORs, consults, or clinics to go around. Surgeries that do happen tend more towards the emergent or urgent, as elective procedures get deferred to the fall when OR time increases.
For those with no interest in becoming a surgeon - like me - it's a pretty good deal. There's a decent amount of time for studying and less time standing in an OR seeing procedures I'll never participate in again. A bit more learning for my long-term career interests, less of a service component. Had some decent impromptu teaching as well, tailored to my career interests. For those who are seriously considering surgery, it's a time to avoid. Too few opportunities to shine or get hands-on learning with direct relevance to a career in the OR. Lots of sharing of experiences with other students, given limited work to do. Physicians are on vacation all the time, meaning few chances to spend more than a week with a single physician, and less time to impress any one of them.
Hard to do much about this when your clerkship schedule is already set, as it is for most people starting their 3rd year in September, but something for me to keep in mind when it comes to planning electives and/or setting up rotations for my residency. To survive surgical rotations, pick the slow times; to thrive, busier times are better. As a non-surgeon, I'm happy with survival.
Monday, 30 May 2016
Beginning of the End (of Clerkship)
One more block left of Clerkship and I'm done. I can see the end of this year in sight, and then it's onto the awesomeness of 4th year electives. With the sun finally coming out as well, it's a fairly invigorating time!
Well, except for the one small detail that the final block standing between me and the finish line is surgery...
I am not a surgeon. My physical skills are fine, I can behave myself in an OR, but my tolerance for the personal and physical sacrifices necessary to make it as a surgeon is pretty low. I don't care how amazing performing surgeries is, I have no interest in doing anything for 12 hours a day every day. Heck, if you told me surgery was playing video games and eating ice cream 12 hours a day, I'd still probably have to say no. And I like video games and ice cream a whole lot more than I like being in an OR.
We had our orientation today for the surgery block and it went really well, but looming over it all was the prospect (promise?) of missing out on a lot of sleep, a lot of life, or both. I'm hoping it won't be as bad as I'm dreading it'll be and/or that my enthusiasm for being on the home stretch of clerkship will carry me through relatively unscathed. It'll all be done in 3 months, one way or another, so I suppose I should just strap in for the ride.
Well, except for the one small detail that the final block standing between me and the finish line is surgery...
I am not a surgeon. My physical skills are fine, I can behave myself in an OR, but my tolerance for the personal and physical sacrifices necessary to make it as a surgeon is pretty low. I don't care how amazing performing surgeries is, I have no interest in doing anything for 12 hours a day every day. Heck, if you told me surgery was playing video games and eating ice cream 12 hours a day, I'd still probably have to say no. And I like video games and ice cream a whole lot more than I like being in an OR.
We had our orientation today for the surgery block and it went really well, but looming over it all was the prospect (promise?) of missing out on a lot of sleep, a lot of life, or both. I'm hoping it won't be as bad as I'm dreading it'll be and/or that my enthusiasm for being on the home stretch of clerkship will carry me through relatively unscathed. It'll all be done in 3 months, one way or another, so I suppose I should just strap in for the ride.
Wednesday, 30 March 2016
Poorly Trained Surgeons
Wanted to share this post, about concerns with surgical resident competencies. This is presented in a US context, but I've heard many of the same worries in Canada. Put simply, a good portion of fellowship directors (and other attending surgeons) believe that a fairly significant number of graduating surgical residents are not competent to perform important surgeries independently. Worse, many of these surgical residents agree.
The kicker for me, however, is this paragraph:
"The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening."
I've had a few glimpses of this myself - residents, even residents far along in their training, rarely get a chance to operate in a truly independent manner. It's all dependent on the attending surgeon of course, some are more comfortable letting residents take a larger role than others, but the overall proportion seems skewed against letting residents really gain independence. I've seen first-hand a PGY-5 start off leading a surgery, only to be bumped when the first, relatively minor complication arose. That's not a great way to get that PGY-5 to a point of competency when they graduate in a year (for the record, the PGY-5 was excellent from a surgical perspective relative to their peers, I really can't fault the resident here).
More junior residents had it even worse. For the most part they were assisting with the odd opportunity to do some small parts of the surgery, but opportunities were generally based on whoever else was in the room (fellows and senior residents getting priority), attending comfort, and other considerations beyond the resident's control such as timing. The skill level or educational requirements for the resident only rarely seemed to factor into things... they mostly just got left with whatever scraps of learning they were lucky enough to gather.
When it comes to a procedure - any procedure - the only way to gain competency is to do it, on your own, over and over. Sure, supervision is essential, especially in high-risk procedures, which includes pretty much any surgery, but supervision could be a lot more arms-length than it currently seems to be for surgical residents. More importantly, progression could be a lot more deliberate and standardized, rather than set by the whims of the attending on the day, whims that could hold a resident back from performing tasks they're fully able to complete - or tasks where trying to complete it is the next step in their education - while on the flip side, could push a resident to attempt a task they're not ready to try, yet they do because it may be their only chance at it in quite some time.
Back to the article - the author makes a suggestion that, while logical given the current constraints, hits at the profound dysfunction in a lot of medical education:
"All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively."
In short, work harder. Hope your superiors let you learn.
Time and time again, I see this pattern, and it's far from being unique to surgery - medical education providing ineffective or inefficient instruction, with the only proposed solution being sheer volume of exposure. Residents dutifully follow this approach, doing everything they can to gain competency, but their options are often limited - too many learners, not enough procedures to help with, many other responsibilities and only so much time in a day. Volumes can only go up so much.
At some point, those doing the instructing need to be held accountable for poor outcomes of their learners, but even they are typically victims of this dysfunctional model of medical education. They weren't often taught in an effective or efficient manner and, more importantly, few are ever taught how to teach. The system perpetuates itself, unfortunately.
The kicker for me, however, is this paragraph:
"The lack of confidence stems from the gradual increase in supervision of residents over the last 15 to 20 years. In yet another blog post, I pointed out that many of today’s residents rarely if ever operate independently during residency training. To realize you are on your own as a full-fledged surgeon without ever having performed a case by yourself must be frightening."
I've had a few glimpses of this myself - residents, even residents far along in their training, rarely get a chance to operate in a truly independent manner. It's all dependent on the attending surgeon of course, some are more comfortable letting residents take a larger role than others, but the overall proportion seems skewed against letting residents really gain independence. I've seen first-hand a PGY-5 start off leading a surgery, only to be bumped when the first, relatively minor complication arose. That's not a great way to get that PGY-5 to a point of competency when they graduate in a year (for the record, the PGY-5 was excellent from a surgical perspective relative to their peers, I really can't fault the resident here).
More junior residents had it even worse. For the most part they were assisting with the odd opportunity to do some small parts of the surgery, but opportunities were generally based on whoever else was in the room (fellows and senior residents getting priority), attending comfort, and other considerations beyond the resident's control such as timing. The skill level or educational requirements for the resident only rarely seemed to factor into things... they mostly just got left with whatever scraps of learning they were lucky enough to gather.
When it comes to a procedure - any procedure - the only way to gain competency is to do it, on your own, over and over. Sure, supervision is essential, especially in high-risk procedures, which includes pretty much any surgery, but supervision could be a lot more arms-length than it currently seems to be for surgical residents. More importantly, progression could be a lot more deliberate and standardized, rather than set by the whims of the attending on the day, whims that could hold a resident back from performing tasks they're fully able to complete - or tasks where trying to complete it is the next step in their education - while on the flip side, could push a resident to attempt a task they're not ready to try, yet they do because it may be their only chance at it in quite some time.
Back to the article - the author makes a suggestion that, while logical given the current constraints, hits at the profound dysfunction in a lot of medical education:
"All you can do as a surgical resident is to try to scrub on as many cases as possible and take care of as many patients as you can. With luck, you may have faculty who have enough confidence in themselves to allow you some autonomy and decision making in the OR and when managing patients pre-and postoperatively."
In short, work harder. Hope your superiors let you learn.
Time and time again, I see this pattern, and it's far from being unique to surgery - medical education providing ineffective or inefficient instruction, with the only proposed solution being sheer volume of exposure. Residents dutifully follow this approach, doing everything they can to gain competency, but their options are often limited - too many learners, not enough procedures to help with, many other responsibilities and only so much time in a day. Volumes can only go up so much.
At some point, those doing the instructing need to be held accountable for poor outcomes of their learners, but even they are typically victims of this dysfunctional model of medical education. They weren't often taught in an effective or efficient manner and, more importantly, few are ever taught how to teach. The system perpetuates itself, unfortunately.
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