Clerkship Director: Dr. Kristi Harold
Clerkship Length: 8 weeks
The surgery clerkship is a total of 8 weeks comprised of two weeks on a general surgery service (either colorectal, vascular, or pediatrics at PCH), two weeks of a surgical subspecialty (a ton of variety - you don’t get to pick), two weeks on ACS/Chief Service (you’re assigned to a chief resident on the Acute Care Surgery service), one week in the ICU, and one week on anesthesia. The hours are long, but there’s a lot of variety in each day and the eight-week duration makes studying for the shelf exam more manageable.
Grading for the surgery clerkship is based on a points system:
HONORS = >85 points
HIGH PASS = 65-84 points
PASS = 45-64 points
FAIL = <45 points or <10% on Shelf Exam (2021-2022 EPC norms have this at a 63% correct)
Components of the Points System
Aside from scoring >10th percentile on the Shelf Exam, none of these have hard cutoffs for Honors/High Pass (i.e. you can bomb the oral exam but if you do well enough on the Shelf and the points average out, you can still Honor).
Clinical Assessment (25%, 25 points): based on Medhub evals from your faculty/residents
NBME Shelf Exam (25%, 25 points):
**values below based on 2020-2021 EPC norms found in Brightspace**
85% or above (83% correct) = 25 points
70-84% (80-80% correct) = 20 points
40-69% (73-79% correct) = 15 points
10-39% (63-72% correct) = 10 points
Oral Examination (25%, 25 points): 15 minute one-on-one Q/A discussion with Dr. Harold and/or Dr. Pearson. Based on a list of topics provided. They guide you through it - you have to have a basic knowledge of how to workup a patient, but you don’t have to be 100% correct to score well. No questions about surgical technique… the goal is to determine if you can say “yes go to OR” or “no, not a surgical problem”.
Honors Level = 25 points
High Pass Level = 20 points
Pass Level = 15 points
Marginal Pass Level = 10 points
Fail Level = 0 points
Topic Presentation (15%, 15 points): basically a 5ish minute presentation on a list of topics covered in the oral exam. Low stakes, low pressure.
Here is what a typical student schedule might look like.
General Surgery Weeks (general surgery, colorectal, peds, or vascular):
The schedules vary a little bit for this depending on which service you’re on - the ones at Mayo are typically 5am start time for handoff. Evening sign out is at 5pm… if you’re not interested in surgery it’s pretty rare to stay this late. If there aren’t a ton of cases going on it’s reasonable to be sent home around 3-4pm. They also typically don’t expect you to stay for a case that’s starting after around 3pm because it’s guaranteed to make it a late day. You’ll probably have a couple of late days just with how OR timing works out, but overall 5-5 is a reasonable expectation with a few earlier days sprinkled in. 5d/week.
Day-to-day schedule:
5-530: signout
530-645: round on your patients (usually two) with or without the intern and write their progress note
7-8: morning conference - educational, in Room 115 near the cafeteria (exception = Tuesday for M&M in Waugh)
Note that these are for the residents to prepare for their ABSITE exams. If you have a question, jot it down and ask a resident or the presenter after.
8-afternoon: surgery (woohoo!)
5-530pm: signout
ACS/Chief Service Week:
5am start for handoff - you’re assigned a chief but you’ll mostly be working with the interns that are on ACS that month. Similar to general surgery weeks - sign out is at 5pm so you can expect to leave around 5:30, but depends on the OR schedule. 5d/week. Conference is 7-8.
You will be added to ACS patient list by one of the residents
Ask your chief if they want you to come to clinic with them. Usually they have one clinic day a week.
Try to follow patients that are under your chief’s care, and volunteer to see consults when they are on call.
Under “Things to do”, the chief and intern that patient is assigned to will be listed.
Subspecialty Weeks:
TONS of variety - anywhere from 5a-7a start time and lots of variation in end-time depending on the schedule (i.e. transplant is a wild schedule, ortho tends to have a more reliable case schedule to follow).
Neurosurgery:
Neurosurgery morning rounds start at 5:40am in the 3rd building (closest to parking garage) on the 7th floor. There is a conference room in the back office area where they meet. If you take the elevators closest to the staff cafeteria to the 7th floor, start walking down the hallway, then take a left you will enter a large office space. Neurosurgery is roughly in the middle and residents can be found there.
Table rounds last about 1hr, then the whole team goes together to the ICU, and will usually split off from there. This is a good opportunity to practice your neuro exam.
Honestly, neurosurgery is what you make of it. It is very easy to be forgotten about and the surgeons hardly ever write evaluations. I would recommend trying to hunt down your surgeon (or ask a resident to) and asking if you should go to clinic with them. Try to go to at least one case a day, and afternoon rounds start at 1pm with the PAs and NPs. You can also volunteer to see consults. You can certainly also take time to study between cases.
Tumor board and other conferences usually start at 7pm and you ask to join if you are interested.
ICU:
6a-6p - 5d/week.
Residents will usually send you home early
Anesthesia:
You will be assigned an attending that you work with M-W, Th-Friday you will get someone different for variety.
6:30a-4:30p - 5d/week.
Usually sends you home early
If you are unsure of who you are working with on Thursday and Friday, email/talk with Dr. Stokes
General Surgery Weeks (general surgery, chief service, colorectal, vascular):
Resident work room is located in the main hospital, 2nd floor towards the central wing.
Neurosurgery
On the 7th floor on the clinic building (closest to the garage). The neurosurgery area is roughly in the middle of the office space. Morning rounds are in a small conference room on the 7th floor close to the offices. Usually need to bring your own rolling chair since there is usually not enough chairs for morning rounds.
ICU:
Main hospital, 2 West (new wing)
H pod: CT patients
G pod: Multidisciplinary (neuro and abdominal) patients
Anesthesia:
Main hospital, 2nd floor (right past the central elevators)
Across from entrance to OR hallway. You will go into a pre-op area and then through the door straight ahead to enter anesthesia offices. You will go to the last office at the end of hallway which is the resident pod. Just ask for an empty desk.
Evaluations
Surgery can be really intimidating, especially if you haven’t spent a lot of time in the OR before. The attending staff and all of the fellows/residents know this and respect that you’re not supposed to have an understanding of complex surgical technique. Try to relax and just follow what’s going on during the case - staying engaged (this doesn’t mean asking a question every five minutes, it means just not getting super distracted in the OR) will go a long way.
You’re going to get asked questions in the OR - look at the board for the next day and take time to read through the cases so you have an idea of what’s going on. Review relevant anatomy, especially neurovasculature that can cause complications. StatPearls is a decent resource for this, as are YouTube and SAGES videos.
Practice suturing a few days before you start - you should be able to close port sites with simple interrupted and larger assist ports with a running sub-q.
Be able to do a single-handed knot tie.
OR RULES
Don’t assume you’re going to scrub with a new attending - it’s okay to ask! If there’s an attending, fellow, chief, and two interns, you probably don’t need to scrub.
If you can, go introduce yourself to the patient in pre-op and see if there is any questions/concerns they have.
If you are going to scrub, introduce yourself to the scrub tech and ask if it’s okay to drop your gloves on the table. Ask for help getting gloves and gowns from the core if you have never done it before.
(IF YOU DON’T KNOW HOW TO DROP GLOVES OR A GOWN, DO NOT GUESS. You’ll contaminate the entire back table if you do it wrong. Ask for help! Scrub techs are generally wonderful and happy to teach.)
Write your name on the whiteboard and introduce yourself to the circulating nurse so they can add you to the case log.
Head to the room when the status board turns orange.
It’s okay to take a few minutes to run to the restroom, eat a *quick* snack, or grab a sip of water before a case.
Try to avoid going in/out of the room once a case is going. If you’re there when they start, you should be there until they finish.
You can ask to put in the Foley
Leave your phone, pager, badge/etc. on the table with the circulator when you scrub. That way if your pager goes off, no one has to dig under your gown to find it and return the page.
After the case is completed, put on some gloves to help transfer the patient. Grab the bed, offer to help move the patient, and walk with the patient to post-op.
For more info about the OR you can review Success in the OR page
General Service Stuff
You can stand out by knowing the details about your patient. Don’t try to follow everyone on the list (sometimes it’s 30+ long) - just know what’s going on with your people.
Surgery-specific things to know:
I&Os - if they’re not charted, call and ask
ROBF (return of bowel function - have they passed gas or pooped?)
What’s their diet?
Basic labs - and TRENDS!
Discharge barriers
Don’t be afraid to touch base with case management/social work for dispo planning.
KEEP YOUR PRESENTATIONS BRIEF.
One-liner: 44yM with PMH of (only relevant things) admitted two days ago for acute cholecystitis now POD#1 s/p robotic assisted cholecystectomy with Dr. XX.
Overnight events: ROBF/Nausea/Vomiting, any acute changes
Vitals (okay to just say “stable” or “within normal limits”)
I&Os
Any updated imaging
Plan for today (be able to argue if patient should go to surgery or not, and if they are progressing appropriately)
Oral Exam
15 minutes with Dr. Harold and/or Dr. Pearson. It’s structured very similar to the surgical oral boards - they’ll give you a case and ask you to walk through the workup. If you “order” a CT, they’ll give you the relevant positives and negatives/etc. The goal of this is not to test your surgical knowledge or information about specific techniques, it’s to determine if you know how to handle a surgical ED consult and if you can call a surgical emergency when it presents. They really guide you along - if you don’t know, take an educated guess and explain your reasoning. This oral exam is much easier than OBGYN oral exam. You will also review the topic with presentations beforehand.
Oral Exam Prep - outlines for all the topics
Shelf Exam
It’s a tough one - the curve is reasonable, however the breadth of content can be a bit overwhelming. Some helpful resources:
Pestana’s Surgical Review - quick read that gives a good overview of basic surgical things. Paper copy in library.
UWorld - there’s a LOT of questions but it’s doable over the eight weeks if you keep up with it. I’d recommend going through the entire bank and redoing incorrects if you have the time.
AMBOSS - the knowledge sheets are INCREDIBLY helpful. Everything in surgery is based on a flowsheet - get familiar with some of the basic algorithms and patterns for working up surgical problems and you’ll be golden. Some of the AMBOSS questions are a little above the level of the Shelf, but good practice.
Emma Holiday lecture - watch the night before as a quick last-minute review. It’s on YouTube, right at 2 hours.
Mehlman free high yield guides/anki
DeVirgilio’s surgery textbook. Super high yield for both the shelf and pimping. It is an easy read and goes through a patient case with questions. A copy is available at the library
Something that was not covered well on my question banks was pediatric surgery and cancer treatment (surgical removal vs chemotherapy vs radiation) so these might be good topics to review. Also review EKGs!
Topic Presentation
12-ish minutes, they’ll send out a list of topics to choose from halfway through the clerkship. Very low stakes - designed as a time for you to review for the oral exam. You’re only presenting to Dr. Harold and the other med students on clerkship.
*most important resources are in red that you should do at minimum to pass
UWORLD
You know where to find that!
Question bank is about 630 total questions - it can help to do some of the GI section from medicine too.
Do it all at least once!
AMBOSS
NBME Practice Exams
Online MedEd or Osmosis
Check their respective websites for the videos
Here is the Online MedEd PDF booklet that you can scan quickly for review
Oral Exam
Here is a link to all topics with review content for your review
Touch Surgery App (free)
DeVirgilio’s surgery textbook
Mehlman free high yield guides/anki
Click here for Sample Study Schedule in Excel
Before Clerkship: watch Online MedEd videos/ Osmosis OR read Pestana’s book
Goal of 100 UWorld Questions per week
Last two weeks - review incorrect questions, watch Emma Holiday Lecture
For Epic Templates
Feel free to steal from SmartPhrases - just search Megan Campany (or Isabella Reitz) in the Smart Phrase Manager. I grabbed them from one of the chief residents so they’re fairly standardized to what they expect! Otherwise you can ask your residents or attendings to copy their templates too.
Content to Review
Hernias and relevant groin neurovasculature
Gallbladder disease (biliary colic vs. choledocholithiasis vs. acute cholecystitis vs. ascending cholangitis and labs for each)
Diverticulitis - types of complicated diverticulitis
Management of small bowel obstruction (conservative = NPO/mIVF, NGT, +/- Zosyn → gastrografin challenge)
Abdominal wall layers
Indications for emergent OR (i.e. common causes of peritonitis, volvulus, closed loop obstruction, perforation)
ICU Helpful Readings
Since you only spend one week in the ICU, the most important thing to learn is when a patient needs to go to the ICU vs when they can be managed on the floor (or PCU). These links are helpful for a deeper understanding of ICU management (beyond the Brightspace readings)
Ventilation readings:
Vasopressors and Inotropes
Sedation:
Phoenix Children's Hospital:
Dr. Harris is the medical student director at PCH for general peds surgery, but not everyone will necessarily work with her. The other surgeons include: Dr. Lee, Dr. Jamshidi, Dr. Notrica, Dr. Molitor, Dr. Padilla, and Dr. McMahon.
You will receive an email from a PCH administrator with contact info for the PCH fellows. Please text them both at least a few days in advance before you start date so they can provide the location of where to meet and what time
PCH gives you 2 scrub credits (meaning you can only have 2 pairs of scrubs at one time)
The machines to retrieve and return scrubs are located next to the main entrance of the OR on floor 4
Locker room is adjacent to the scrubs dispenser machine
Rounding begins at 5:45 - 6 am
Recommended to meet in the resident workroom on floor 2 at 5:30 am since the residents will need to print the patient list for you (med students do not have access to the patient list) and the residents leave at 5:45 am to walk from the resident workroom to the NICU to start rounds (which begin at 6 am in the NICU - walk w/ the residents)
Sign out begins at 7 am after rounding (usually in the APB room)
Recommended to take notes during sign out since some of the attendings ask how their admitted patients are doing so know positive/negative findings on imaging, lab findings, overall status (pain, n/v, npo, NG output, etc.)
Dr. Harris will give you a brief orientation and assign you to an attending on your first day
You are required to follow your attending to most of their cases.
You are allowed to ask their permission to see other cases from other attendings if there is a more educational/interesting case going on.
There is no requirement to write notes.
It is recommended to read up on all the surgical cases (attendings will ask what you know about the patient they are operating on) and to know the basics of the procedure (anatomy especially)
Be curious and ask questions only when appropriate (some attendings are passionate about teaching, but if there is a delicate, intense step during the surgery that requires their full concentration, do not ask questions during this time).
You are required to follow your attending to their clinic. Attendings usually have clinic 1-2 times per week. Wear business professional and ask the attending beforehand if there are patients you can do a H&P on or can see independently. Each clinic visit is 15 minutes or less so read up on the patient beforehand and keep the interview short so you have time to staff with the attending.
Afternoon sign out is at 4pm in the APB room/sometimes in conference room on 4th floor. Recommend going to sign out, especially if your attending is in charge of new consults for that week or if your attending is on trauma call.
Residents and fellow sometimes dismiss you/sometimes don’t. It is sometimes at your discretion when you can leave. If no resident/fellow/attending says to leave, then recommend going to sign out and leaving afterwards.
Last updated in October 2023 by Isra Abdulwadood
Log Cases in MedHub
Log Work Hours in Med Hub
Complete MedHub Evaluations
Shelf Exam
Oral Exam
Topic Presentation
Complete one CEX
Last updated in September 2024 by Izzy Reitz