Surgery Clerkship Review

I'm not going to lie.  I was dreading the Surgery Clerkship.

I don't particularly like being miserable - that sounds like an obvious statement for anyone to make, but I can assure you as you get to know medical students, you will find that some people not only love it but thrive on it.  Anyway, I don't particularly like being miserable, and I don't mean to be a drama queen, but I hate being tired.

I'll give a little background on the surgery rotation first, for those of you who are not in medical school. It's known as the big daddy of the rotations.  The hardest to get through.  The longest, most grueling hours.  The most stressful day to day work.  Moment to moment suffering as egotistical god complex ridden surgeon's pimp you (where they ask you rapid fire questions you can't hope to answer and belittle you for you for your wrong answers) and generally crap on you.  An older student told me on his surgery rotation that he slept three or four hours a night.  That's fucked up.

I was dreading it for all of those reasons, but I was also dreading it, because I was sure I wasn't going to be a surgeon.  See the thing about surgery is that for many surgical specialties, the stressful work environment and long and unpredictable hours keep on going at an only moderately reduced rate.  When you're thirty.  Forty.  Fifty... and into your sixties.

So anyway, I was dreading it because I knew I would be miserable, and I didn't want to suffer through six weeks of misery for a specialty that I knew I wouldn't be interested in.

And the result of my six weeks?

I loved it.

I fucking loved it.

I was on trauma surgery.  At this hospital, trauma surgeons obviously run the traumas that come in, but in between those calls, they work a lot of the standard general surgery cases: hernia repairs, gall bladder removals, etc.  If you think about it, it makes sense.  You need a lot of trauma surgeons at a level one trauma center so someone can be available at all hours with multiple others to back them up... but if you're going to be paying someone 300k a year, then you want them to be doing something when they're not sewing mangled bodies back together.

I'll start with the trauma calls.  This sounds like something that would be exciting as all hell, and some of them absolutely were.  But you'd be surprised by how many were run of the mill "traumas."  We weren't privy to how the actual algorithm works, but basically when an ambulance en route to the hospital calls in a certain mechanism of injury, either it is deemed a trauma and the trauma team is called, or it is handled by the Emergency Department.  Again, I'm not sure exactly how it works, but it considers several factors for a variety of mechanisms.  For example when a patient is injured in a car wreck it is related to the number of cars and how fast they were going and etc.  When it is a fall, it is related to the age of the patient and how far the fell.

When an incoming call is deemed a trauma, we are all paged (yes, even the third year medical students) and immediately drop everything (unless we are already scrubbed into a surgery) and report to the Trauma Bay.  There, we gown up in a ridiculous getup consisting of a full gown, gloves, breathing mask, eye shield, and hair cover.

Trust, me, on the relatively rare occasion that blood is flying everywhere, you're thrilled you have this on, but... that's a relatively rare occasion.  Instead, you may be surprised to know that the majority of traumas are relatively uninteresting.  At least half the time that we are called, it goes something like this: someone comes in from a car wreck that meets the trauma criteria.  They are rolled in by EMS.  They are usually conscious and breathing under their own power.  They may or may not have an obviously broken bone and a few bruises (often neither; but yes, I have seen some spectacularly broken bones).

We then work them according to the trauma algorithm: airway, then breathing, then circulation.  We check for spinal tenderness or deformities as we roll them over and after rolling them back on their backs, we shoot a chest X-ray to make sure there are no acute chest processes that are going to kill them in the near future (pneumothorices, etc).  Then we send them to the CT scanner for a "pan-scan," which is a scan of their head, neck, chest, abdomen, and pelvis.  Then that's usually really it.  Ortho will come see them for the broken bone at some point; maybe Plastics too if there is a facial wound.

Don't get me wrong, these are significant injuries for the patient, but from a trauma standpoint they are relatively benign.  For the most part, we only really worried about injuries that would kill people in the extremely near future.

Also, another point not to get me wrong on: some traumas were considerably more exciting.  At any point in that algorithm, the ship can get derailed if the patient presents abnormally, such as if the airway isn't intact, they're not breathing, or there is a massive breach in the circulation.  I have seen people with massive internal bleeding not make it to the operating room and get cut open in the ED.  I have had blood spilled on my clothes in the ED.  I have seen people bleed out and die before making it to the OR.  I have helped a team save a person's life; while I don't have any illusions that I played a profoundly important role, I can enjoy the knowledge that a person is alive today because the trauma team was there for them, and I was able to assist the team at least in some small way.  That ain't nothing.

But anyway, back to my review of the clerkship... well... did you see what happened there?  I sat down to write a clerkship review and got sidetracked and couldn't stop writing about it... because I loved it.  Back to the review.

The hours on surgery sucked.  There's no way around that.  I did Internal Medicine (considered the second hardest along with OB-GYN) before Surgery, and it was considerably worse on surgery.  I woke up at 3:45 AM for those 6 weeks and dragged my ass into the hospital.  I typically left between 6-8 PM, usually about 7:20.  And roughly every 10 days we had a 26 hour shift where you show up at your usual time in the AM and don't leave for 26 straight hours (honestly, the overnight calls were pretty cool though; with a smaller overnight staff you got to do more... and for some reason the most fucked up injuries tended to come in overnight).  And the work was not relaxing; it was actually profoundly physically demanding, surprisingly so.  On top of that, because there is a difficult test at the end of the 6 weeks, we had to try and study for 1-3 hours when we got home.  It was tough, and by the end of the six weeks I was sick, had accrued a serious sleep debt, was drinking 4-6 cups of coffee today, and really missed my girlfriend and dog.  It was tough.

The surgeon's shitty attitude and god complex was overrated.  For the most part, I really enjoyed the people I worked with.  Some of them were a little eccentric but almost every single one was legitimately likable.  Not tolerable, but likable.  Of the 10 attendings on the team, I only mildly disliked one or two.  One I never had negative interactions with, but he was just a miserable person...  which isn't the best to be around.  The other liked to stick it to students.

If I had to guess where the negativity towards surgeon's comes from, I think it comes down to a few things.  First, there are obviously douchey surgeons with god complexes.  I can even name one (didn't work with him) at our hospital.  That small minority gives the rest a bad name.  Second, they're fucking busy.  Really fucking busy.  And I think this forces them to be relatively brusque with patients.  These patients are sick and miserable and often in a time of profound need where they really want to feel well cared for by the person who will be cutting them open... unfortunately the surgeon's needs and the patient's needs are not well lined up here, beyond that they both want the operation to go as well as possible.  This also relates to a fundamental problem in doctor patient relationships that I see every day, but I'll write about that in another post.  Third is that most of them seemed to have relatively dominant personalities.  Personally, I think I probably fit into that category, so it didn't bother me.  But for other people with less dominant personalities... this can be grating.  I actually think a lot of medical students tend to have less dominant personalities; it makes sense if you think about it: these are people who chose to go into a profession all about serving other people and sacrificed their free time in the process.  You think of more of the dominant personalities going into law or business.  Anyway, you imagine that there a proportionally fewer dominant personalities in medical school than in the general population, and throw them into a rotation with a concentrated group of those dominant personalities who are busy and stressed out all the time, and well... you get it.

And the work.  Surgery.

Well, I wish I could give a better opinion on how I liked that.  Unfortunately (but fortunately for patients), you spend almost no time with the knife in the clerkship.  The best you can do is try to project how you would feel about the technical aspect of it.

I think I mostly liked it.  I liked some of it a lot and some not so much.  The routine, minimally invasive surgeries bored the hell out of me.  After seeing the two or three gall bladder removals, I lost complete interest.  On the flip side, the bigger, more open traumas or hernia repairs were interesting.  I guess it's childish, but I think I was more interested in the bigger surgeries because the guts and gore was fun.  The minimally invasive surgeries were less interesting for that same reason.

I think the thing that I liked most about it was that I could see surgery as both a science and an art.  One thing that bothered me so much about Internal Medicine was that it was so algorithm based.  If this then that but if not this then that, and etc and etc.  While the medical management around surgery was algorithm based, and the decision of whether or not to go to surgery was algorithm based in most cases (with individual preference in others)... within the actual realm of surgery itself... it was art.  It was skill.  Decisions to do this vs that were made intra-operatively.  One surgeon's technical skills and proficiency made a difference to a patient's outcome.  It was beautiful.

And the last thing I loved is the opportunity to provide definitive care to a patient.  There is no endless talking to them or counseling them about the importance of taking drugs.  Less dealing with noncompliance.  Less time spent watching a chronic process slowly kill your patient.  Some specialties have those things, but in many, many surgical specialties, for most cases a patient presents you with a problem, and the surgeon has the opportunity to perform a definitive intervention on that problem.  Cut out the appendix.  Cut out the Gall Bladder.  Perform a Carotid Endartectomy.  And without their Appendix, your patient will go on to their pre-morbid life.

There were some things I didn't like.  I saw a 50 and 60 year old surgeons so tired they fell asleep in meetings held at 6 AM.  I was told about the virtual inevitability of getting sued (surgical specialties are sued more often than their medical counterparts).

The worst part as far as I'm concerned, though is that the training length and difficulty is horrifying.  It first requires a 5 year General Surgery residency.  After that, most surgeons do a two year Fellowship (Trauma for example, to stay topical).  And note that if you want to do a competitive subspecialty, like pediatric surgery, you're almost required to do a two year research fellowship in order to place into the pediatric fellowship.  All that, well... that asks a lot of a person.  A lot.

Just to do some basic math for me: I'm 25 right now, and I'll be 26 soon.  I'll graduate from medical school when I'm 27.  5 years of General Surgery takes me to 32.  Two years of Fellowship (let's forget the research for years for now) takes me to 34.  I would be 34 and for the first time in my life would actually get to start my career and make an income more proportional to my level of training and effort.  Put differently, I would be working 80-90 hours a week until the age of 34.  That weighs on a person.  That's not healthy.  That's my youth.  The last bits of my youth.  No money and no time until 34.

What scared me was talking to some of the Interns (first year residents) vs some of the older residents.  The interns were still fresh (two months in when I was there) and excited about surgery... but you could tell that many of the older residents didn't feel that way anymore.  I remember one resident telling me how residency "just breaks you."  Scary shit.

So in the end what can I say?

I loved surgery.  I really did.

And over the rest of the year, as I decide what I want to do with my life, I'm going to have to do some soul searching.  How much am I willing to suffer?  For how long?  How much do I like my second favorite career choice?  Or maybe I'll do another rotation that I'll love even more than surgery.



Note: I actually did my surgery rotation a couple months ago but only posted the review now.  I hope to post a few reviews of other rotations I've done, some of which may be recent and others even older than surgery.  Ignore the timeline and focus on the ideas.