Student-Informed Guidelines on Preparing for the Core Surgery Clerkship

Key Learning Points

After reading this resource, medical students should be able to: 

• Understand their basic role on a surgical team
• Efficiently and effectively prepare for an upcoming operation 
• Optimize personal time, performance, and well-being while on the surgery clerkship

We get it. Preparing for the surgery clerkship—a rotation known for its long hours and unfamiliar culture—can be daunting for medical students.^1,2 Moreover, operating room (OR) protocol as well as an emphasis on self-directed learning often leaves students uncertain of what to expect in their daily schedule and how to best plan. Efficient routines, focused preparation, and disciplined self-care enable students to perform at their best and enjoy their surgery clerkship. Even for students who plan to pursue a non-surgical career, the surgery clerkship is an opportunity to learn the entire spectrum of medical and surgical management while simultaneously practicing teamwork and hands-on skills.³ In this resource, we provide recommendations grounded in firsthand experiences and medical education theories to assist medical students in preparing for and excelling in their surgery clerkship.

Managing Expectations

At most institutions, students should expect to work hard during their surgery clerkship, as they adjust to OR etiquette, earlier mornings, and a multilayered knowledge base. In return for consistent effort, students can expect positive outcomes in their relationships with patients, in their evaluations from team members, and in their own learner satisfaction. In our experiences, students have the most confusion about the schedule, team structure, and surgical culture of the surgical clerkship.

Schedule

 While hours vary based on the specific rotation, rounds commonly begin around 6:00 am. If pre-rounding on patients beforehand, students can allot 20–30 minutes per patient to start, understanding they will become more efficient with time. Surgical cases typically begin around 7:30 am, and students may be assigned multiple cases with brief breaks in between. Students will be dismissed home after their cases finish and/or after afternoon rounds or evening sign-out (6:00 pm).

Team Structure

Typically students will work closely with the intern on patient care and floor tasks. The senior resident will assign cases, direct patient care, and spend most of their time in the OR. Students may be assigned to the OR alongside another resident, who is an excellent resource for questions and guidance throughout the cases.

Surgical Culture

While the surgery clerkship is a demanding and, at times, uncomfortable experience, students should not experience mistreatment and disrespect.^4–6 Students are encouraged to speak to a trusted advisor or clerkship director if this occurs. Developing early relationships with residents and patients has been shown to improve the student experience in the surgical clerkship.⁷

Preparing for Patient Care on the Inpatient Floor

A critical component of the surgery clerkship is assisting with patient care on the floor. Students can be helpful to the surgical team by taking on level-appropriate tasks and understanding basic perioperative complications and management.

Students are generally expected to pre-round on their patients prior to rounds each morning. Pre-rounding should include reviewing overnight events and patient data in the OMR, getting report from the overnight resident if applicable, and visiting their patients to get their subjective report of the night (pain control, new symptoms, etc.) and perform a focused physical exam. During morning rounds, students should plan to give a brief oral presentation on their patient(s) to the team. This report should include a one-liner, overnight events, subjective details, fluid intake and output, vitals and physical exam, relevant data (new labs, imaging, or microbiology results), patient assessment, and plan for the day (clarify the format and level of detail with your team beforehand). Students can carry supplies in their pockets and white coats to be prepared for tasks as they arise during rounds or throughout the day, such as changing a dressing or flushing a nasogastric tube (Figure 1). After rounds, students may be asked to help with various floor tasks such as writing progress notes, calling consults, communicating with nursing staff, and performing postoperative checks. As students grow in efficiency and competence, they may take on more tasks and responsibilities, eventually becoming more proactive and independent.

Students should learn about perioperative management and common issues that arise, including postoperative pain, urinary retention, ileus, infection, and electrolyte/nutrition imbalance. These topics are widely applicable to other medical specialties besides surgical ones and will help the student become a better physician overall. Students will quickly learn these topics through direct patient care and may supplement this learning by consulting resources such as OnlineMedEd or Dr. Pestana’s surgery notes.^8,9

Preparing for the OR

One of the primary expectations for medical students on the core surgery clerkship is to come to the OR prepared. A simple framework that clerkship-level medical students can use to guide their preparation is to know the patient, know the procedure, and know the anatomy. 

Know the Patient

Before the operation, students can read about their patient’s history in the electronic health record. They should focus on the patient’s initial presentation for surgical treatment and what work-up they have received, including labs, imaging, and staging. The patient’s past medical and surgical history, social history (substance use, functional status, occupation, home support), and medications are all pertinent to the operation and the postoperative care plan. 

Know the Procedure

Students are not expected to know all steps of every operation. Instead, they should consider the following components: why does this patient need this particular operation, what is the intended outcome of the procedure and what are the basic steps needed to achieve that outcome, and, finally, what are common intraoperative and postoperative complications that may arise. Students may also consider reviewing prior operative notes for the upcoming procedure, which has an added benefit if the operative note was created by the surgeon who will be performing the case. A great resource that students can use to prepare for all relevant components of an operation is Zollinger’s Atlas of Surgical Operations, which can generally be accessed for free through an institutional login. Specific chapters correspond to specific surgeries that are frequently encountered. Current Surgical Therapy is another utilized resource. ^10,11

Know the Anatomy

Medical students are frequently asked about relevant anatomy in the OR. To prepare, students should consider the function of the organ or structures that are being operated on and how the operation will affect that function. Students should review the key arterial supply, venous drainage, and innervation of the major structures relevant to the operation. Finally, they should consider the important surrounding structures that could be injured during the case. Much of this can simply be looked up online, but Moore’s Clinically Oriented Anatomy is a commonly used, clinically-relevant anatomy resource.¹²

While this is a lot of information to study before each operation, students should start with knowing the patient and progress to knowing the procedure and anatomy as they are able. Over the course of the clerkship, students will gradually build up their knowledge base as they see an operation multiple times. 

While students often fear being asked questions in the OR, this is an expected and integral component of surgical learning. Questions offer students the opportunity to demonstrate knowledge and to identify their specific knowledge gaps. It is not expected that students will know every answer, and many surgeons ask questions to understand students’ knowledge levels and then offer relevant and useful teaching accordingly. Students are also encouraged to ask questions during downtime before and after the operation, and during parts of the operation when the situation allows such as the opening and closing phases. 

As in all fields of medicine, students may, unfortunately, come across physicians who are not good educators.³ Students can notify their clerkship director or advisor about interactions and/or educators that detract from their rotation experience. Issues of professionalism and respect should be taken seriously and elevated accordingly.

Managing Time at Home (Maintaining Work-Life Balance)

In many programs, the core surgery clerkship can be a logistically and emotionally intense time for students, regardless of intended specialty.⁶ Optimizing performance and well-being on the clerkship should not only entail academic preparation but also thoughtful scheduling of meals, social time, studying time, exercise, and personal rest. The following list is intended to provide practical suggestions for maintaining balance based on our collective experiences.

• Today starts yesterday: Following personal time and dinner, students can use the evening to prepare for the upcoming day. In addition to studying for the Surgery NBME Subject Exam, evening preparation likely involves reviewing patient charts, studying for upcoming cases, and pre-packing meals.
• “Transit” time is study time: Capitalizing on time while commuting or waiting for a case to start will create hours of study time from small segments of minutes. Spending 15 minutes multiple times a day on spaced repetition—via the Anki phone app—or listening to an educational podcast (Goljan, Divine Intervention, USMLE Step 2 Secrets) can have a big impact over the course of your clerkship.^13–17
• Anticipate physical needs: The unpredictability of the OR schedule and the physical challenge of surgery makes readily accessible food a must. For satiety and fuel, students should consume food high in protein throughout the day, and keep pocket snacks such as almonds, dried edamame, energy bars to have during breaks in the OR schedule.¹⁸ On every OR break, students should drink some water and go to the bathroom. If urgent needs arise while students are in the OR, they can excuse themselves to address them. If a student feels faint during surgery, they should notify the team, step away from the OR table, and sit down.¹⁹
• Downtime isn’t found, it’s scheduled: The key to a sustainable schedule is prioritizing personal rejuvenation. Understanding what is individually important—social time, exercise, more sleep, or alone time—and allocating time for it throughout the week ensures not only that it happens, but also that it is enjoyed guilt-free. 

Preparing for the Surgery NBME Subject Exam

Performing well on the Surgery NBME Subject Exam is achieved through selection of foundational and supplementary resources, a well-planned study schedule, thoughtful review of chosen question banks, and integration of knowledge gained both in the surgical and medicine clerkships. Importantly, the education literature confirms that excellent clinical performance on the surgical clerkship is reflected in Subject Exam success.¹⁷

Prior to their clerkship, students should select 1 question bank, 1 recommended foundational textbook, and 1–2 supplementary resources, with the question bank being the most important resource (Figure 2). Attempting to utilize too many resources can result in poor retention as well as an inability to keep pace with a study schedule. Following selection of the materials, a study schedule should be created (via Excel, calendar app) that prioritizes completion of the question bank in the clerkship time interval and realistically integrates relevant supplemental material.

The question bank is necessary and invaluable to success on the Subject Exam and should be used in conjunction with foundational textbooks. Maximizing the utility of this resource can be achieved by:

• Simulating the test taking experience through timed question blocks
• Thoroughly reviewing explanations for missed questions
• Recognizing familiar question patterns and the expected diagnostic workup and management

 As the medicine and surgery Subject Exams have significant overlap, investing in the clinical experience in both the medicine and surgical clerkships will not only improve confidence and practical skills, but will also reap critical academic dividends. Additionally, especially if students have not yet had their medicine clerkship, they may find it helpful to review questions from the medicine question banks, particularly those related to the renal and gastrointestinal systems. To supplement the question bank students may read portions of a textbook that focus on presentation, workup, diagnosis, and treatment of common surgical conditions, while various additional resources can be referenced for quick review of key topics. Students should try to complete at least 1 timed practice test, or NBME Subject Exam “Self-Assessment,” to get familiar with the testing format and style of questions.

Notably, some programs may additionally require an oral exam. In addition to the preparation above, we recommend students verbally work through surgical cases with fellow students––paying particular attention to appropriate diagnostic workup and management of common surgical problems.

Conclusion 

With these tips in mind, students can excel on the surgical clerkship. As on any rotation, being engaged, understanding your learning needs, and being a good team member are the most important factors for excellent performance. Students should remember to have fun and enjoy the amazing and unique experience of caring for surgical patients.

References

1. Burney CP, Goldwag JL, Sorensen MJ, Crockett AO. Hopes, fears, and rumors: Medical students and the general surgery clerkship. American journal of surgery. 2021;222(4):687-691. doi:10.1016/j.amjsurg.2021.06.013
2. Castillo-Angeles M, Watkins AA, Acosta D, et al. Mistreatment and the learning environment for medical students on general surgery clerkship rotations: What do key stakeholders think? American journal of surgery. 2017;213(2):307-312. doi:10.1016/j.amjsurg.2016.10.013
3. Soualhi A, Munajjed O, Kraria L. The impact of medical student interest in surgery on clerkship performance and career choice. American journal of surgery. 2020;220(2):505. doi:10.1016/j.amjsurg.2019.12.001
4. Hasty BN, Miller SE, Bereknyei Merrell S, Lin DT, Shipper ES, Lau JN. Medical student perceptions of a mistreatment program during the surgery clerkship. American journal of surgery. 2018;215(4):761-766. doi:10.1016/j.amjsurg.2018.01.001
5. Kemp MT, Smith M, Kizy S, Englesbe M, Reddy RM. Reported Mistreatment During the Surgery Clerkship Varies by Student Career Choice. Journal of surgical education. 75(4):918-923. doi:10.1016/j.jsurg.2017.10.011
6. Stone JP, Charette JH, McPhalen DF, Temple-Oberle C. Under the knife: medical student perceptions of intimidation and mistreatment. Journal of surgical education. 72(4):749-753. doi:10.1016/j.jsurg.2015.02.003
7. McKinley SK, Cassidy DJ, Mansur A, et al. Identification of Specific Educational Targets to Improve the Student Surgical Clerkship Experience. The Journal of surgical research. 2020;254:49-57. doi:10.1016/j.jss.2020.03.066
8. Online Med Ed. Surgery: General. Published 2022. Accessed April 20, 2022. https://onlinemeded.org/spa/surgery-general
9. Pestana C. Dr. Pestana’s Surgery Notes: Top 180 Vignettes of Surgical Diseases. Fifth. Kaplan Publishing; 2020.
10. Ellison E. Zollinger’s Atlas of Surgical Operations, Ninth Edition. McGraw-Hill Education; 2010. https://books.google.com/books?id=9on8IiReVxoC
11. Cameron AM. Current Surgical Therapy. Elsevier; 2019. https://books.google.com/books?id=G1zyxgEACAAJ
12. Dalley AF, Agur AMR. Moore’s Clinically Oriented Anatomy. Wolters Kluwer Health; 2021. https://books.google.com/books?id=SHhTEAAAQBAJ
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15. Goljan E. Goljan Pathology Lectures. Published 2017. Accessed April 20, 2022. https://www.podbean.com/podcast-detail/3r4gz-62103/Goljan-Pathology-Lectures-Podcast
16. Divine Intervention. Divine Intervention Podcasts. Published 2022. Accessed April 20, 2022. https://divineinterventionpodcasts.com/
17. O’Connell T, Inside the Boards. USMLE Step 2 Secrets (An InsideTheBoards Podcast). Published 2020. Accessed April 20, 2022. https://podcasts.apple.com/us/podcast/usmle-step-2-secrets-an-insidetheboards-podcast/id1434924694
18. Leidy HJ, Todd CB, Zino AZ, et al. Consuming High-Protein Soy Snacks Affects Appetite Control, Satiety, and Diet Quality in Young People and Influences Select Aspects of Mood and Cognition. The Journal of Nutrition. 2015;145(7):1614-1622. doi:10.3945/jn.115.212092
19. Morzycki A, Hudson A, Williams J. Medical Student Presyncope and Syncope in the Operating Room: A Mixed Methods Analysis. Journal of surgical education. 73(6):1004-1013. doi:10.1016/j.jsurg.2016.05.003
20. UWorld | Test Prep for NCLEX, SAT, ACT, MCAT, USMLE & More! UWorld Test Prep. Accessed August 22, 2022. https://www.uworld.com
21. AMBOSS: medical knowledge platform for doctors and students. Accessed August 22, 2022. https://www.amboss.com/us
22. de Virgilio C, Frank PN, Grigorian A. Surgery: A Case Based Clinical Review. Springer New York; 2015. https://books.google.com/books?id=DmUqBgAAQBAJ
23. Subject Examinations | NBME. Accessed August 22, 2022. https://www.nbme.org/assessment-products/assess-learn/subject-exams