Surgery

Jump to Surgery Electives

Ron Gerald Landmann, ‘00, updated by Sunny Jun and Cassandra Lee, ‘01

Boston Medical Center

Students choose between BMC (HAC or ENC) and the VA as sites for the surgery rotation. The VA systems merged this past year so that the surgery wing at the Jamaica Plain VA will be shut down. Therefore, we currently do not know what the status of surgery rotation at the VA will be. We anticipate that students will now be sent to the West Roxbury VA. During your surgery rotation either at HAC or ENC, you will have an opportunity to do one-and-a-half weeks in a surgical specialty (urology, orthopedics, anesthesiology, pediatric surgery, cardiothoracic, neurosurgery, etc.). The remaining weeks will be spent on the inpatient service. You will not find out which elective and which outside hospital you are doing until approximately one month prior to starting your surgery rotation. Charity Stafford, the Medical Student Education Administrator, managed to give everyone either their first or second choice this past year. Understand that each elective has a different number of spots available - therefore, rank your electives wisely and be realistic in your chances of getting your "top" choice. If you have any strong desire for a particular outside hospital or elective, let Charity know in advance via email at charity.stafford@bmc.org.

The chief residents take turns presenting cases at "Becker rounds" held each week in the early morning. DO NOT COME IN SCRUBS, and be prepared to stand for an hour. You will find that these presentations are a very good way to learn (and review) certain subjects in Surgery. All students (BMC and VA) must attend weekly Grand Rounds and Morbidity and Mortality (M&M) conferences. The latter is perhaps the most important conference to attend. There, different cases ranging from the most basic to the most complex with the different complications are presented. Students should take this opportunity (usually with heated discussion between attendings and residents) as an educational one. You will learn what to do and what NOT to do the next time a patient presents with certain symptoms.

Students also have faculty preceptors assigned by the department. There are scheduled meetings with the preceptor, in which students present and discuss patients. This is a good chance to really get to know one of the surgery attendings and for him to get to know you. His evaluation counts the most towards your final clinical grade.

Harrison Ave Campus

At HAC there are two teams, A and B, each with two interns, a fourth year resident, and a Chief Resident. One of the fourth year residents will be a Tufts resident who is doing a trauma rotation. The teams trade off admitting patients every other day. Call schedule is dependent on the number of students on both teams (i.e. one student covers both teams every night).

Anonymous writes: "When on call, the student should be with the fourth year resident (this rarely happens). HAC is a great experience for those of you who are thrill-seekers and want a good dose of action. You'll see everything from people jumping off 5 story buildings to gunshot wound patients. Moreover, you'll have the opportunity to see the workup of a trauma patient from the ER and then straight to the OR. As a 3rd year medical student you have first priority in scrubbing in on trauma cases which is a protective policy against overzealous 4th year surgery sub-I’s. In order to see all this, it's important that you follow your 4th year resident around like a puppy dog - because when the **** hits the fan – you’re going to be the last thing they will be thinking about. So my advice during your third year clerkship is to assist your interns, but to follow around the seniors for your education."

Call provides an opportunity for the most one-on-one teaching from the residents/attendings if the student is assertive and asks lots of questions. Be prepared not to sleep when you are on call. It is not uncommon to be awoken at 11 PM for an emergency appendectomy and at 2 AM for a trauma case that requires a human retractor (i.e. YOU). Expect to arrive for pre-rounds 30-45 minutes prior to the actual morning rounds as dictated by your chiefs. This will depend on how efficient you are. Always be on time!

In the OR you will see many bread and butter general surgeries (lipomas, hernias, and laparoscopic cholecystectomy) as well as trauma. There is limited exposure to many of the attendings. However, the Dr. Millham, the residency director, is in Critical Care at BMC and operates primarily there, so you may get more chances to work with him. Every Friday morning at 7:30, Dr. Hirsch, Chief of Trauma Surgery, has "Gorilla Rounds" in the SICU. This has been called one of the most terrifying experiences of the surgery rotation. A resident presents a patient from the SICU in what may seem to be excruciating detail. Dr. Hirsch pimps the residents (mostly) and students (rarely, and usually just Sub-Is) on questions ranging from equations used to calculate lung volumes to why certain steps were taken in the care of the patient. You can learn so much in this one-hour session so pay close attention. You will never know when Dr. Hirsch will call on you next! Remember: for the most part, the questions asked during Dr. Hirsch’s rounds are basic general surgery questions – any third year student that thinks about the question should get the answer. Take your time and do not be intimidated. DO NOT FALL ASLEEP.

Four of five afternoons will be spent in Surgery Clinic from 1-4 in ACC-5. This is an opportunity for students to evaluate new patients, follow-up established patients, and perform minor surgical procedures. You will probably see about 4-5 patients/afternoon. The downside to clinic is that you have to present your patient to a resident or an attending and finding one or the other is very time consuming. Overall, clinic is a good experience. Every afternoon, except Friday, there will be a conference from 4-5 PM. These are educational and required, and once every 3-4 weeks they may have food.

East Newton Campus

The surgery clerkship at ENC is an excellent site to learn the basics of General Surgery. The majority of time will be spent in the OR. You will see little to no trauma cases at this site. There are three services at ENC: Smithwick (Vascular), Mozden (Oncology), and Chief (General). You will be assigned to one of the teams and will work under a chief resident, senior or junior resident, and first or second year intern. There is ample opportunity to participate in OR cases of services other than the service you are assigned. The student has a position of responsibility. You will carry your own patients, present them to the team during morning rounds, and follow them pre- and post-operatively. The call schedule varies depending on the number of students on all the services (like HAC, one person takes call for all the services per night). It is overnight call, and you share a call room with the Sub-Intern. The students are expected to be at morning and afternoon rounds, morbidity and mortality conferences, Grand Rounds, and the didactic sessions specifically for students. Faculty at ENC is excellent and is very interested in teaching, both in and out of the operating rooms.

JP VAMC

Ron G. Landmann, ’00 and Denise Gee, ‘01

Hours for students at the VA average from 6 AM to 6 PM. There is an employee parking lot that makes parking easy (especially at such early hours!). At the VA, you will become proficient in minor procedures including peripheral venous blood draws, arterial sticks, and minor wound debridement. You will be able to observe Swan-Ganz catheterizations and central line insertions. There is also a variety of general surgery performed at the VA although vascular cases do predominate. Students see approximately 2-3 cases per week in the OR and spend the rest of their time on the floor managing patients. For the outpatient experience, surgery clinic occurs twice a week. The rest of your time at the VA is divided between weekly lectures and various conferences (vascular, GI, etc.) Once a week, you attend Grand Rounds at BMC. Your call schedule will vary depending on the number of students on the service, but students rarely have to stay up all night. Although the call room is warm in the summers and cool in the winters, it is a large room with a telephone and television. Meals are free for students on call. There is a main cafeteria/food court on the third floor (which is closed on weekends) and a deli on the first floor. Overall, students enjoy their time at the VA while gaining solid exposure to the surgical field.

The VA has one incredible experience that is unfortunately not offered at the other sites. Students would be wise to take advantage of the pig lab by the faculty at the VA. While there are usually only 2-3 sessions per block, students learn suture tying and suture technique while performing complex GI cases, including gastrojejunostomies, on anesthetized mammals. This is quite a fun experience – and you learn at the same time.

* Please note, that this information may be obsolete as Surgery is now held at the West Roxbury VA. Most of the information should be pertinent though.

Surgery @ Community Hospitals

Brockton Hospital

Nathaniel Clark, ‘01

Brockton is located approximately 35 minutes from the door of the medical school. It is a community hospital, and performs a high volume of basic surgeries. You will see plenty of laparoscopic cholecystectomies, appendectomies, breast biopsies, etc. (this will make sense third year, trust me). The hospital also has its share of the more rare, interesting surgeries. Students will have the opportunity to be in the OR all day.

Some of the surgeons are very motivated to teach and ask questions, particularly Drs. Corey, Paulson, and Grotz. Other surgeons tend to ask fewer questions and have a more laid-back approach to student involvement in the procedures.

The commute is not the worst, especially if coming from Boston, since you are traveling opposite the flow of traffic. However, living arrangements are provided for the students. These consist of single rooms with a bed, desk, and shared bathroom in the nursing school behind the hospital. The accommodations are Spartan but comfortable. The heat works. The dorm is located 2 minutes from the door of the emergency room. The surrounding area is quite safe. Parking is available for free.

When I was there, students received about $3.00 in credit per meal. The food is cafeteria food, but three dollars can go a long way. Since there are usually only four students per rotation, call is q4. As with all rotations third year, your evaluation and experience will be almost completely dependent on the residents and interns you will be working with. Good residents can make the difference between a positive experience and one that is not. Therefore, I would encourage you to choose your away rotation with this in mind.

Cape Cod Hospital

The Cape Cod Hospital is located in Hyannis and has the nickname of "Camp Surgery." When you arrive on your first day, expect to scrub in first thing. Upon your arrival, you will get a brief tour of the hospital, be shown how to scrub (if you don't know how), and then be thrown right into the OR. The housing for the rotation consists of a renovated house across the street from the hospital that may house 4-6 students. It was redone in the summer of 1995 so it is very livable, although somewhat bare. Linens are available at the hospital. There is no need to bring an extensive wardrobe, since you are advised to wear scrubs throughout the day. You will need to bring one set of decent clothes to wear one morning a week for conference. A bonus of Cape Cod Hospital is that food for medical students is free.

A typical day starts at 5:30 AM with rounding on patients and writing daily progress notes. You will see patients by yourself, write progress notes, and report to your intern or resident on any important patient issues. Breakfast is usually from 7:15-7:30 AM and surgeries begin at 7:30 AM. You can scrub into as many surgeries as you would like on a given day, typically 2-5 surgeries per day. You may be asked to write H&Ps and/or work-up patients in the ER. Call varies according to the number of students; usually it is every third or fourth night. Since the house is across the street and only a two-minute walk away from the hospital, you can go home between surgeries or when you are on call. Your weekends are free unless you are on call, but all students are required to attend the Saturday teaching conference at 8:00 AM and Grand Rounds at BMC regardless of call status. There is some teaching by various attendings at the Cape, although sessions are often canceled due to the high volume of surgeries, especially in the summer. Overall, the Cape is a good rotation for great exposure to community surgery, with the opportunity to scrub into 20-50 surgeries.

Roger Williams Medical Center

Ron G. Landmann, ‘00

As in the Medicine Rotation, there are great things and not so great things about Roger Williams (RWMC). RWMC is most well known for its radical Surgical Oncology procedures performed mostly by Dr. Wanebo. He performs some procedures that no one else in the world does. One of these procedures is a 2-3 day affair - but you may never see anything like this ever again. If you are genuinely interested in general surgery (and liked watching M*A*S*H re-runs), this is definitely an experience not worth missing. Students perform up to 10 surgeries per week. The range of cases spreads between appendectomies and hernias to head & neck, plastics, and major surgical oncology cases. At RWMC, your experience is also what you make of it. You can work as much, or as little, as you want. Some students chose to concentrate on their readings, while others dove into doing as many surgeries and procedures as possible - in fact, at RWMC, you will have the most opportunity for placing central lines, arterial lines, Swann-Ganz (Pulmonary Arterial) catheters, and broviac and Port-A-Caths. Some students also got the opportunity to be 1st Assist or primary surgeon on major cases - from appendectomies and hernia repairs to hemicolectomies and pericardial windows! (Alas, Whipples are still the domain of attendings and residents). You will be working with a PGY-3 Surgical Resident from BU and a Surgical Oncology fellow from RWMC's own program. This gives you a tremendous amount of responsibility in the management of your patients. A typical day starts at 7:00 AM with rounds (pre-rounding before), and ends at 7-8 PM depending on when Dr. Wanebo's clinics end. However, there is a great deal of down time when you can catch up on readings for the exam or for the presentations at conferences that students actively participate in. There are Head & Neck conferences, Radiation Oncology, Breast, M&M, and thoracic conferences - all of which students are encouraged to present in. There is also a weekly student-driven literature review with just the students, the BU resident, fellow, and Dr. Wanebo. Additional teaching is provided by Drs. Koness, Avradopoulos, and Weaver. Call is Q4, however, students were rarely called into the hospital at night. Depending on your scheduling, students may only have to be down at RWMC for 1 weekend the entire month. An additional plus for those students tired of "scut" – the ancillary staff at RWMC is great - you never have to draw blood unless you want to (or it's an emergency, of course). In all, I had an excellent rotation down at RWMC where I gained lots of hands-on experience in general and oncologic surgery - with great teaching to boot!

Daniel Oates, ‘00

This is a good rotation, and it gives you a nice chance to get away from Boston for a bit. There will be four of you here and you will live in nice housing that is a block or less from the hospital. Two of you live in one house and two in the other (you’ll share the house with the students down there for medicine).

A typical day starts with pre-rounds at about 6:30. We tried to get our notes written before rounds, but your resident (who will be a PGY 3) will tell you what they want from you. Rounds start around 7:00 and you will only round on the Surgical Oncology patients. After this you will spend you day either in the OR or reading in the library. There is very little scut here, as it is a private hospital and the nurses do most of the work. As a side note, the nurses on 4 West are probably the best nurses you will ever see in your medical career. All of us were amazed by how much they cared about their patients and how good they were at what they did. They will treat you nicely as well, which is a bonus!!

Picking up patients is a bit confusing here. There are patients that belong to the surgical oncology service and the fellow will tell you about their arrival. These are the patients you will round on as a team. There are also general surgery patients who usually come in through the ER. Picking up these patients is a bit of a hit or miss, as often one of the surgeons will run into you in the hall and tell you to see a patient in the ER. We found that usually it was the person on call who would pick up these patients, as the PA who staffs the ICU would get a call about them and pass the info along to the on-call student. However you will not round on general surgery patients as a team. You will see them and write a note, which will be co-signed by the attending at some point during the day.

Overall everyone has found it to be a good experience down at RWMC. Make an effort to work with Drs. Vito and Koness, as they are quite nice and will teach you. Also be forewarned about Dr. Wanebo’s clinic on Tuesday and Friday afternoons. It can literally run until 8 at night, with some patients waiting three hours to be seen. Dr. Koness has clinic on Tuesday afternoons, so you may want to work in his clinic instead. In the OR you will get a chance to see lots of laparoscopic cholecystectomies, appendectomies, A/V fistula creations, and some very unique surgical oncology cases with Dr. Wanebo. Beware, however, as some of his cases can be long (i.e. taking more than one day!!!).

Surgery Electives

Anesthesia

Sunny Jun, ‘01

Anesthesia is the way to go for those of you who would like a break from surgery. You arrive every morning around 7-7:30AM in the OR and get assigned to the floor attending who will guide you throughout the entire day. Depending on the cases you go into, your days can end as early as 12 PM or as late as 5 PM. There are NO calls or weekends. The attendings don't keep track of you so you can basically leave anytime you want. You will have the opportunity to see surgeries from ALL different specialties. For example, if you're interested in Urology, you can choose to go into those cases only. I had the chance to see ENT, urology, Ob/Gyn, and general surgery cases.

Not only is the exposure to the variety of surgical subspecialties appealing, you actually perform many procedures (i.e. intubating, placing A-lines, injecting spinals, etc.). The attendings are very nice in allowing you to get the most experience out of this short rotation. The more interested you are, the more they will let you do. So make use of this elective to get as many intubations as you possibly can. Another good aspect is that the attendings and residents CONSTANTLY teach. You will learn the basics of both pharmacology and physiology through this elective. Also, you will finally get to experience what goes on at the other side of the operating table.

You can take advantage of this easy elective to get some extra sleep and reading done!

Orthopedic Surgery

Cassandra Lee, ‘01

Orthopedics can be done at either HAC or ENC. At HAC, you will work mainly with Dr. Tornetta, head of orthopedic trauma. Hours are EXTRMELY long, but it is a phenomenal and rewarding rotation. You will learn the basic orthopedic physical exam as well as observe a variety of orthopedic surgical procedures. You arrive at 5:15 to round, have 6:30 x-ray conference with Tornetta, and are in the OR by 7:30. Your day usually ends by 7 or so. Grand Rounds are every Monday at 7:15 where visiting professors or chief residents will lecture give presentations. On Wednesdays, there are additional teaching conferences at HAC (ENC attends also), sometimes held by Dr. Leach, former Chairman of Orthopedics and a world-renowned orthopedist, as well as by professors from the orthopedics lab and various departments. These teaching sessions are extremely helpful in that you will learn what some of the basic measurements in orthopedics entail, how basic science correlates with the clinical picture, and the pathophysiology of disease.

Time can be spent in the OR or following the second year orthopedics resident doing consults on the floors or in the ER. If you follow the resident, you may see basic orthopedic procedures such as reducing fractures, casting fractures (you may even get to do this), measuring pressures within the compartments of muscles, etc.

At ENC, you will observe more sports medicine orthopedics, spine surgery, and arthroscopic procedures. Your experience will all depend on how many visiting fourth year students are in attendance. I personally had to struggle with a visiting fourh year student to get some OR time at HAC.

You may take call, but I warn that this is one of the most vigorous calls you will ever take in surgery. When I took call, I was running all night between radiology, consults in the ER, and general inpatient floor work.

Otolaryngology

As a third year clerk in Otolaryngology (ORL), your main responsibility is to learn how to perform the head and neck exam. You will participate in clinic two days a week. Depending on your skill level, you will be allowed to examine patients and write notes. Concise oral presentations are highly valued. You will spend several hours a week in the OR. The types of cases you will see depend on whether you are at BMC or the VA. In general there are three areas of surgical interest: head and neck, otology and pediatric. You can prepare for cases the night before the surgery.

Which book you use depends on what you are studying for. A good head and neck surgical atlas will save time but are hard to come by in our library. For head and neck cases, Netter will suffice. For information about the diseases, Cummings edited a 4-volume treatise on the topic of ORL. Remember that otology and pediatric ORL are specialties unto themselves and require specialized books. A pocket book on the wards was valuable for me in every rotation. In this specialty it is very difficult to find one book with all the meat in it. If you plan on entering the field on ORL, I would recommend that you look at the "Essentials of Otolaryngology" by Lucente, or the book by DeWeese. Your goal in the third year is to understand what the field is about, find out if this is what you want to do, and prepare yourself for the general surgery exam. Continue to read NMS for your general surgery exam in the evenings, as the days can be very long. There was no call during my rotation.

Josh Kessler, ‘99

Otolaryngology is an excellent choice for an elective in your third year no matter what field you plan on entering. You will be exposed to many aspects of the ENT regardless of where you do your elective.

At BMC, you will have the chance to work with all of the attending staff, who are generally pleasant and interested in teaching. You will round with the residents in the morning around 6:30 AM at HAC and then, depending on the day, spend your time in clinic or the OR. In the clinic, you may need to be aggressive but you will be allowed to see patients on your own and present them to the attendings. This is an excellent time to learn about common ENT problems such as otitis media, tinnitus, vertigo, tonsillitis, and hoarseness. These are all problems that you will encounter no matter which field you enter. In the OR, you will observe common procedures such as endoscopy, adenoid/tonsillectomies, myringotomies with tube placement, etc. You will also scrub in on larger cases, such as parotidectomies, neck dissections, and other complex procedures. Finally, on Tuesdays, you will observe otology cases and learn about middle and inner ear anatomy.

At the VA hospital, you will work primarily with the residents, rounding around 7 AM and then going to the OR, or to their very busy clinic. You will see many vets with hearing problems and head and neck cancer and work them up on your own. Most of the OR cases are endoscopies, otology cases, functional endoscopic sinus surgeries (FESS), and head and neck oncology cases. The attendings at the VA are also very nice and will teach you when you present to them.

Above all, this is the time to see if ENT is a field that interests you and to study for the general surgery exam. There is no call at either location, so study at night for surgery and enjoy your weekends.

Pediatric Surgery

Urology

One student is assigned to each of the primary hospitals (ENC, HAC, and BVAMC) for the three-week urology rotation. As a third year student you are able to participate in all departmental activities and function as an integral member of the urology team. A wide variety of clinical problems are encountered, including urologic oncology, male infertility, erectile dysfunction, urinary calculus disease, neurourology, urodynamic evaluation, female urology, and reconstructive urology. As a member of the team you are expected to round with the residents in the morning and with the attending physician in the evening, assist in the OR, consult other services on urological problems, admit patients, write progress and post-op notes, perform H&Ps, and participate in all departmental conferences. This three week rotation is recommended not only to students who are interested in a urology residency (they should definitely do a fourth year Sub-Internship in urology), but also for students who are interested in other areas of medicine. Urology is a rapidly changing and exciting area of medicine and rotating on the urology service is highly recommended for every future physician, especially those interested in primary care. Avoid the VA because the patient load is a lot less and you don’t see the cool stuff!