Five Reasons I loved my Longitudinal Integrated Surgery Clerkship

by Sophia Kim McKinley


“I don’t understand.”

This is the most common response when I tell people that during my third year of medical school, I did all of my core rotations simultaneously for a year. As a student in the Cambridge Integrated Clerkship, I was paired with an attending physician in each discipline for 12 months and juggled clinic sessions, operating room days, inpatient weeks, and didactics for seven different fields. While most medical students participate in traditional block rotations, I was learning the fundamentals of clinical medicine in a longitudinal, integrated model. “Longitudinal” refers to the fact that my experience in each field stretched across a year, “integrated” refers to the opportunity to follow individual patients across multiple disciplines.

An example of one of my most memorable days was when I had radiology teaching rounds followed by a pediatrics clinic in the morning and internal medicine in the afternoon. In the early evening, I conducted a home visit on one of my geriatrics patients. Then, I was paged to labor and delivery because a prenatal patient had presented with regular contractions. At 2 A.M. when the fetal monitor suggested distress, I scrubbed into her C-section. Within 24 hours, I had been a student in radiology, pediatrics, internal medicine, and ob-gyn.

What the longitudinal, integrated model meant for my surgery rotation is that I had half a day of clinic per week in addition to one day in the OR. Four weeks of time on the resident-led inpatient team was distributed across the year, but most of my rotation was spent learning from my preceptor, who was the surgical chair. Many surgeons have expressed some skepticism about this introduction to surgery, but here are 5 reasons I loved my longitudinal integrated surgery clerkship.

1. Continuity of Care – I was able to follow individual surgical patients across an entire year. For example, I met a woman with newly diagnosed colon cancer in June and continued to participate in her care until the following May. I was present at her pre-op cardiology clearance all the way to her first follow-up CT scan. Six months after I finished my third year, she called me to ask if I could be present for her ventral incisional hernia repair.  
2. Continuity of mentorship – My surgical attending taught me for months in a row. He became very familiar with my strengths and weaknesses both inside and outside the OR, and I was constantly challenged based precisely on my learning needs. When he was on call, he would send me text messages and I would go to the hospital to assist on urgent and emergent cases.
3. OR privileges for a year – need I say more? I spent all my free time for the entirety of my third year going to the OR and scrubbing cases. The OR staff became like a second family, the attending surgeons all got to know me very well, and I had the chance to practice technical skills regularly for 12 months straight.
4. Side-by-side comparison – Because I was doing all seven disciplines at once, it was easy to figure out which field attracted my interest the most. I always looked forward to Mondays, because those were my days to go to the OR. I lamented Monday holidays because there wouldn’t be elective cases scheduled. I couldn’t stay away from the OR. The other fields were great, but it was clear my future was in general surgery.
5. View into the life of an attending surgeon – While my classmates in the traditional block rotations may have finished third year with a better understanding of the life of a house officer, I certainly had an excellent perspective on life after residency. Because my primary teacher was an attending physician, my surgical rotation reflected the workflow of an attending surgeon from how he spent his time to the kinds of relationships he had with patients. I still had some insight into life as a resident during my 4 weeks of dedicated inpatient time, and my fourth year surgical subinternships were another way to expose myself to what life during surgical residency might be like. I’m happy to have had both types of experiences during medical school.

A longitudinal integrated surgery rotation isn’t available at every medical school, but they are becoming more common. Here are a few links and papers to read about this model of third year clerkships:

• NYTimes Well Blog (http://well.blogs.nytimes.com/2012/04/19/reinventing-the-third-year-medical-student/)
• American Medical News (http://www.amednews.com/article/20111226/profession/312269951/2/)
• Teaching medical students about cancer impact through a longitudinal surgical experience: a case study. (2012) (http://www.ncbi.nlm.nih.gov/pubmed/22490098)
• Educational outcomes of the Harvard Medical School-Cambridge integrated clerkship: a way forward for medical education. (2012) (http://www.ncbi.nlm.nih.gov/pubmed/22450189)

What are your thoughts on the longitudinal integrated surgery clerkship? What are surgical rotations like where you train(ed)? Given the option, which type of clerkship model would you prefer?

~~~

Sophia is a dual-degree M.D./Ed.M. student at Harvard Medical School and the Harvard Graduate School of Education. She received the 2012 Association of Women Surgeons Patricia Numann Medical Student Award and spent a year as a Zuckerman fellow at the Center for Public Leadership at Harvard Kennedy School. Sophia is passionate about medical education and she hopes to be an academic surgeon who brings educationally-sound innovations to surgical training. Her clinical interests are gastrointestinal and minimally invasive surgery. Sophia will be applying for general surgery residency during the 2014 Match cycle.

Welcome to the New AWS Blog & Tips for Surviving Your Surgery Clerkship

We're proud to share the launch of the AWS blog with you, and hope that this will provide a new resource for you. We'll be posting at least once a week, trying to spark a conversation with you--usually about a topic that relates directly to being a woman surgeon, but also about things that relate to life in the modern day. Mostly, we do want this to be a place for conversation, for thought, for discussion, and we look forward to getting to know you better through that dialogue. If you have a topic of interest you would like to see us address, please let us know. Those of us writing for the blog and the leadership of the AWS are interested in creating a community space, and to do that, we need to hear your voice.

Welcome!

Amalia Cochran, MD, FACS, FCCM
Secretary, Association of Women Surgeons

Surviving Your Surgery Clerkship

by Lauren B. Nosanov

I was asked to help compile some words of advice for students entering their third year of medical school, specifically addressing tips for surviving the surgery clerkship. Surgery was my first rotation of my third year, and by far my favorite. That said, I know that many students do not enjoy it nearly as much, and experience a great deal of anxiety thinking about it. As such, I have decided to share here those pointers which I thought would be universally applicable.

General Pointers

• Be excited about the OR! 
• Surgeons love the OR and they want you to also, even though they accept that most rotating students will not end up applying to a surgical field. Don't shirk your duties outside of the OR, but do your best to spend as much time observing and participating in operations as you can. 
• Learn the basics of the OR: 
• how to scrub (you will be taught this at the beginning of the clerkship - pay attention, sterile technique is important!) 
• how to not accidentally scrub yourself out (few things raise the ire of an attending / resident as much as a med student who scratches their nose and then contaminates the surgical field!) 
• what is sterile in the OR and therefore should be avoided when not scrubbed (pretty much everything draped in blue is a good rule of thumb) 
• where to stand and observe to have a good view but not be in the way (when in doubt, ask) 
• Anatomy, anatomy, anatomy. 
• This is 90% of what you will be pimped on, and good knowledge of relevant anatomy makes it much easier to figure out what is going on in the OR. Go back and review the relevant parts of your notes from first and second year lectures and labs. Make sure you know what cases your team will be doing if at all possible and study up the night before. 
• Learn to tie and to suture ASAP. 
• Students who can demonstrate these abilities are more likely to be allowed to do things in the OR other than retract. Take advantage of the surgical skill center and the amazing people who work there and practice, practice, practice. 
• Be confident. 
• Surgeons tend to be straightforward and sometimes even a bit impatient. When you present, speak up, speak clearly and most importantly, speak concisely. This will earn you respect, and in turn you are more likely to receive more teaching, more opportunities to see and do cool procedures, and (of course) a better grade. 
• Help your team by becoming a walking cabinet - you will be thanked endlessly time saved and hassle avoided. At a minimum, consider carrying (in white coat pockets or a bag): 
• radiology order forms 
• sliding scale forms 
• trauma forms 
• suture removal kits 
• staplers 
• suture 
• sterile gloves in your size and your resident's size 
• sterile saline 
• syringes 
• marking pens 
• kerlix 
• 4x4s 
• tape 
• extra copies of the team's patient list 
• Be gracious when you are allowed to close at the end of a case. This educational opportunity comes at a cost to everyone else (mostly in the form of time, as you are inevitably slower than your resident closing or stapling). Your appreciation to the OR support staff and your residents will not go unnoticed, and you will likely find that you are given opportunities to close more often. 
• When on call, don't forget to pack: 
• lots of healthy snacks you can carry in your white coat pocket (think string cheese, ziplocs with nuts, granola bars, bananas, PBJ) - eat when you can to keep your energy up! 
• deodorant, toothbrush and toothpaste, washcloth, extra glasses / contact lenses - anything that will help you stay feeling clean and refreshed 
• cell phone charger (nothing worse than being 20 hours in to your shift and realizing your phone is dead) 
• books / study materials for potential down time 
• Don't tolerate abuse and mistreatment, but try to have a thick skin. Remember that surgery is stressful, and that the well-being of the patient comes before your feelings. That said, if you feel your are being mistreated, speak to whoever is in charge of your clerkship and report - keeping your mouth shut won't help you or your fellow students. 

Study Resources

• NMS Surgery Casebook: great for learning how to assess and manage surgical patients 
• NMS Surgery: fantastic, concise bullet-pointed information about common surgical conditions; helpful for reading up on your patients' diagnoses each night 
• Pestana Review: case-based review, this is the Surgery equivalent of Goljan Path (very valuable!) 
• Surgical Recall: nice coverage of basics of surviving a surgical clerkship; best resource for commonly asked pimping questions (and answers!) 
• Surgery Blueprints: Clinical Cases; a lot like Case Files but more true to the types of questions asked on the Shelf 
• Access Surgery: great website for reviewing basics of surgical cases and conditions - load on the computers in the OR immediately prior to a case for last-minute review; requires a subscription (many medical schools provide students with access) 
• As with all clerkships, Pretest, First Aid and Case Files may come in handy depending on student preference 

Cross-posted on November 1, 2012 at metamorphosistomd.blogspot.com

What resources did YOU use to prepare for your surgery clerkship? What other general pointers do you have for students who wish to excel during their third year? 

Share your thoughts in the comments! Let us know what else you would like to see featured on the blog!

~~~

Lauren Nosanov is a fourth year medical student at the University of Southern California Keck School of Medicine. She has spent the last year as a Dean’s Research Scholar, dedicating her time to clinical research in the field of Trauma and Critical Care. Having loved surgery from the very beginning, she is excited to embark upon the process of applying to General Surgery residency this fall. She is passionate about issues surrounding surgical education, mentorship and finding a balance between motherhood and medicine. Outside of medicine she enjoys practicing Taekwondo and spending time with her husband and son.