Coolest case as an intern

[sponch]

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What are the three coolest cases you did as an intern? I'm talking about actually doing it...not being the third or fourth person scrubbed and being the Yankauer jockey or driving camera...if you want you can tell us the name of your program. 🙂

 

[Castro Viejo]

What are the three coolest cases you did as an intern? I'm talking about actually doing it...not being the third or fourth person scrubbed and being the Yankauer jockey or driving camera...if you want you can tell us the name of your program. 🙂

Gastrostomy tube placement with my Chief Resident doing nothing but helping me expose (which I guess really is the case, but who knew at the time?).

First time I touched the insides as the "operating surgeon."

Cool as crap, man...

 

[Winged Scapula]

For many of us, the cases we did as interns where we were doing at least 50% of the case will never qualify as "cool". Its been a long time for me, but they would probably all be inguinal and ventral hernias.

 

[fishmonger69]

lap chole, inguinal hernia, peg tub placement.

an i/d of butt pus can be cool for interns if you don't get into the or much.

 

[46&2]

Young guy with Crohn's comes in with a small bowel obstruction to a small hospital.

Ex-lap + detorsion + resection of 8 cm segment of small bowel with primary anastamosis.

The attending told the R3 to take me through it. She scrubbed it, stood by, and took a cursory feel inside the abdomen. A strong attending, she made the key insights to make the procedure easy. She let the R3 (also solid) and I do everything. The guy went home POD#6.

It was awesome.

If it weren't for that rotation and the VA, I'd have done a total of 2 hernias, zero choles, a few lumps and bumps, a toe amputation, and some skin grafts on burns.

You want good cases as an intern, stay away from the university and head for the community.

 

[dr.evil]

Mastectomy -- resident service. Chief told me to read a lot the night before and I would do the case. I marked the lady and off I went. Just awesome.

AV fistula -- We did a ton of these at my place. So many that I walked an intern through a radiocephalic as a chief (man, that was painful but I appreciated it when I was an intern)

open right colectomy with my VERY patient attending (I turned an hour case into 2 hours but it rocked)

not an academic program for sure

 

[Lioness]

Open right hemicolectomy with a hand-sewn anastamosis (that I got to do all of, at the VA)

Ex-lap and repair of gastrostomy from a stab wound (university trauma on a busy night)

2 open G-tubes (one with a chief at the U, one at the VA)

😀

And two months to go!

 

[AlloImmune]

1. laparoscopic graham patch for a perf'd duodenal ulcer. My chief had gone home for the night and didn't want to come back in. Had never used the endostitch before, but my attending walked me through the thing. It must have been VERY painful for her.

2. Small bowel resection with hand-sewn anastomosis

3. Large ventral hernia with component separation.

These have been the things that have made all the rest of the BS of this year worthwhile

 

[tussy]

Hepaticojejunostomy and gastrojejunostomy in a patient with unresectable pancreatic cancer. Was booked as a whipple so we had all day to do it - the senior didn't show up to the OR so i got to do both anastomosis with the staff. Not really doing the case, but still cool for a PGY1.

 

[geekgirl]

ileocecectomy (x2) - diff attendings, very different experiences, both awesome for an intern

AV fistulae - did a few, but one attending in particular would let you sew every single stitch, and the service had a set of intern loupes for these cases, first time with castros, it was awesome

also did an AV graft with an attending who let me do everything. first time with fogarty caths, lots of blood, again very cool.

it's nice to do big cases as a 1. just to get your hands on the instruments and learn the moves. worth all the painful cases. very worth it.

 

[San_Juan_Sun]

I'm still an intern, but here goes:

First surgery I did skin to skin: small umbilical hernia. Loved it.

First chole was awesome. They are all still awesome to me.

First appy was awesome. They are also still awesome to me.

I confess that I don't like inguinal hernias much.

I've done three right colectomies with very patient attendings. Nothing like actually getting to feel (and then cut out) a tumor.

This last month I did a couple of ex-laps, where we opened to take out some colon and find frank carcinamatosis. Nothing like seeing what fulminate metastatic disease looks like, gives you respect for what cancer can do.

It's probably small time to most on this forum, but temporal artery biopsies are fun. Tying off an artery is just cool.

I love abscess I&D, lines, chest tubes also. Heck, I even love closing skin. Bottom line, I love surgery. Getting a bone thrown your way every once in a while makes the normal intern floor work so much better.

 

[Pir8DeacDoc]

We got to do a lot of lumpectomies as interns. After the first week or so we were given a fair amount of autonomy by the staff but they were always there to make sure it went well.

A few open inguinal hernias at the VA.

Couple of tonsillectomies on ENT.

Got to do half of an abdominoplasty. Plastics resident did the other side.
Did a melanoma excision on the scalp and closure totally by myself. The PRS attending verified that I knew what margins I wanted and what I wanted to do so he left the room and let me have at it.

All in all not too bad for an academic program.

 

[sml1120]

1- laparoscopic splenectomy
2- exlap for sigmoid perforation with creation of an end colostomy
3- lap chole

 

[Skialta]

I have been lucky and been in the OR a fair amount as an intern.
1. BKA- tying off vessels and a bone saw...fun
2. several lap choles, two intraop cholangiograms
3. mastectomy
4 Small bowel resection w primary anastamosis
5. I got to throw some intracaporeal sutures in a lap SB resection
6. several perc trachs and PEGS.
7. Appys open and lap

 

[opr8n]

Exlap
tumor debulking
handsewn gastro-J

at 2am in the morning

it was awsome
im surprised my cheif decided to sleep n that one
i know i wont when im a chief

i thinK??

 

[kaos]

lap inguinal hernia repair with mesh
huge a$$ meningioma resection (looked like a head growing out of a head)
VATS (I love thoracic now!)
axillary lymph node dissection for melanoma

 

[njbmd]

For many of us, the cases we did as interns where we were doing at least 50% of the case will never qualify as "cool". Its been a long time for me, but they would probably all be inguinal and ventral hernias.

Agree with this. The best case for me was any inguinal hernia repair that I did with my program director because he always let us do the entire case from skin to skin. Hernias were very "black box" for me until I did about 10 with him. Great cases and great anatomy.

 

[opr8n]

i also got to doa VATS wedge resection skin to skin
and that was very cool as an intern

it was the 10th one i had scrubbed on that 2month rotation
so i felt pretty comfortable

 

[Doc Ivy]

So far this year 4 or 5 lap choles from start to finish as operating surgeon (man, nothing gets my sphinter tone tighter than dissecting the cystic pedicle with the hook cautery)

2 open choles--- (not lap to open, just straight open) pretty cool

1 open appy --- pregnant lady 18 weeks

 

[Fah-Q]

Hemithyroid and open G-tube. Everything else my intern year was hernias and breast lumps.

 

[Castro Viejo]

lap inguinal hernia repair with mesh
huge a$$ meningioma resection (looked like a head growing out of a head)
VATS (I love thoracic now!)
axillary lymph node dissection for melanoma

Lap inguinal hernia repairs and ALND for an intern?

 

[opr8n]

ALND for an intern?

i did ONE as an intern, is it that far fetched?

 

[Winged Scapula]

i did ONE as an intern, is it that far fetched?

I think his point was that those (AND and lap hernias) are not commonly done surgeries by junior residents and are ones with a far amount of potential complications; I wasn't comfortable with AXND until the end of fellowship, so its hard to understand someone allowing an intern to do the case.

Perhaps some of us here differ in our definition of what doing the case is. If the attending is doing the dissection and holding the tissue for you to Bovie, it doesn't count as doing the case.

 

[sponch]

did someone say lap spleen and lap inguinal hernia as an intern? that's pretty amazing considering most interns can't even place trochars without help. i kind of consider both these cases too be "advanced" since you can really hurt someone if you don't know what you're doing. where i train, the lap fellows get real hard ons for these cases. i mean, i know some community surgeons who will send those cases to the university, especially if they don't have a fellowship trained laparoscopist in their group.

 

[Winged Scapula]

did someone say lap spleen and lap inguinal hernia as an intern? that's pretty amazing considering most interns can't even place trochars without help. i kind of consider both these cases too be "advanced" since you can really hurt someone if you don't know what you're doing. where i train, the lap fellows get real hard ons for these cases. i mean, i know some community surgeons who will send those cases to the university, especially if they don't have a fellowship trained laparoscopist in their group.

Yeah.

I guess I"m confused or else programs are letting interns do a lot.

Its not that I doubt that interns are operating and doing a lot of it because it is clear that many do so. But there IS a difference between assisting in a complex laparoscopic or abdominal procedure and actually doing it. If you debulked the tumor and did the anastomosis (not put in a few stitches) or actually did the dissection, then I consider that "doing" the case. But opening and closing, putting in a few sutures, etc. is not the same even if it felt like it.

I suspect that most of what is listed above is super assisting rather than actually doing the case.

I'm sure I will be flamed for saying so, but I agree...interns doing advanced laparoscopy that most fellows are doing? Doesn't make sense to me.😕

 

[opr8n]

I think his point was that those (AND and lap hernias) are not commonly done surgeries by junior residents and are ones with a far amount of potential complications; I wasn't comfortable with AXND until the end of fellowship, so its hard to understand someone allowing an intern to do the case.

Perhaps some of us here differ in our definition of what doing the case is. If the attending is doing the dissection and holding the tissue for you to Bovie, it doesn't count as doing the case.

let me first start by saying that most residentsa t my program (and by direction fo our PD) consider "doing" the case as hoving two compnents
1. performed about 50% or greater of the case
2. performed some part of the "actual operation" in some significant fashion
So i certainly dont think "doing" necessarily means skin to skin especially as residents

 

[Blade28]

*Simple mastectomy
*Lap chole
*PDA ligation
*Hemorrhoidectomy

 

[Castro Viejo]

i did ONE as an intern, is it that far fetched?

I suppose not, but it's hard to imagine as Winged Scapula mentioned. Maybe it's because both she trained and I'm wrapping up my training in the Northeast, where autonomy isn't so tangible as it is in the South or Midwest (?).

Now as a Chief Resident I can do the MRM on my own, but there'd be hell to pay if I started digging in the axilla without the attending on the opposite side of the table.

 

[San_Juan_Sun]

let me first start by saying that most residentsa t my program (and by direction fo our PD) consider "doing" the case as hoving two compnents
1. performed about 50% or greater of the case
2. performed some part of the "actual operation" in some significant fashion
So i certainly dont think "doing" necessarily means skin to skin especially as residents

I mentioned a few above, and when I say I performed the case it means I did at least 50% and completed the essential elements myself. For the lap appys/chole, open hernias, ports I did 100%. Obviously, that % went down depending on the case. But even on the uncomplicated right hemis, I made the incision, entered the belly, mobilized the colon, did the resection and anastamosis, and closed completely. If we encountered tough adhesions or whatever, obviously I have to turn the metz over.

I forget to mention that I did (90%) of a lap ventral hernia w/ mesh. Very cool.

But here's the deal: a lot of us interns get to operate, but under no circumstances am I doing things alone. I have an attending at my side watching me closely, guiding me each step of the way. I am by no means doing the thinking part of the surgery by myself, I'm just proving that you actually can teach monkeys to operate.

And even though I get to do a lot, I know I'm not running a room by myself, with the attending not there or not scrubbing in. That's the major leagues meant for my seniors. I'm just in AA ball, but still having a good time. 🙂

 

[Winged Scapula]

let me first start by saying that most residentsa t my program (and by direction fo our PD) consider "doing" the case as hoving two compnents
1. performed about 50% or greater of the case
2. performed some part of the "actual operation" in some significant fashion
So i certainly dont think "doing" necessarily means skin to skin especially as residents

Performing 50% of more of the case is required by ABS for you to record yourself as Surgeon Junior and was the qualifier I was using to define "doing" the case. Just some of the cases listed above seem to be a little more advanced than I've seen residents do at any hospital i've worked at. Again, I think sometimes junior residents think that doing the case means cutting all the tissue the attending gives them to do, when the real work is the dissection.

Perhaps the difference is definitions as above or in resident autonomy as Castro notes. If it is the former, then I can list plenty of cases in which I probably did 50% but didn't do the "critical" portion of the case (ie, the anastomosis). But it likely could be the latter...no way was I ever doing the dissection in the axilla or doing G-J anastomoses as an intern. I was lucky if I got to do more than drive the camera, fool around with the bag a bit and close the portholes while the 2nd or 3rd year did most of the case in a lap chole.

 

[opr8n]

Performing 50% of more of the case is required by ABS for you to record yourself as Surgeon Junior and was the qualifier I was using to define "doing" the case. Just some of the cases listed above seem to be a little more advanced than I've seen residents do at any hospital i've worked at. Again, I think sometimes junior residents think that doing the case means cutting all the tissue the attending gives them to do, when the real work is the dissection.

Perhaps the difference is definitions as above or in resident autonomy as Castro notes. If it is the former, then I can list plenty of cases in which I probably did 50% but didn't do the "critical" portion of the case (ie, the anastomosis). But it likely could be the latter...no way was I ever doing the dissection in the axilla or doing G-J anastomoses as an intern. I was lucky if I got to do more than drive the camera, fool around with the bag a bit and close the portholes while the 2nd or 3rd year did most of the case in a lap chole.

generally i agree and understand where you are coming from
BUT
im telling you that some interns who the attendings trust get to do more
I did a G-J anastmosis as an intern
I did a VATS wedge biopsy skin to skin
it happens

I have two very different experiences
In med school, its was very traditional
Interns did not close fascia on exlaps
Interns were lucky to get to doa lap chole skin to skin, some didnt do one at all
As a resident, im in a community program
while it varies hosptial to hospital and attending to attending
some interns get to do more than others

 

[opr8n]

But here's the deal: a lot of interns get to operate, but under no circumstances am I doing things alone. I have an attending at my side watching me closely, guiding me each step of the way. I am by no means doing the thinking part of the surgery by myself, I'm just proving that you actually can teach monkeys to operate.
And even though I get to do a lot, I know I'm not running a room by myself, with the attending not there or not scrubbing in. That's the major leagues meant for my seniors. I'm just in AA ball, but still having a good time. 🙂

well said

 

[Winged Scapula]

generally i agree and understand where you are coming from
BUT
im telling you that some interns who the attendings trust get to do more
I did a G-J anastmosis as an intern
I did a VATS wedge biopsy skin to skin
it happens

I have two very different experiences
In med school, its was very traditional
Interns did not close fascia on exlaps
Interns were lucky to get to doa lap chole skin to skin, some didnt do one at all
As a resident, im in a community program
while it varies hosptial to hospital and attending to attending
some interns get to do more than others

I'm glad you are getting the experience you are, it will be very valuable to you.

Your medical school experience sounds like my residency one.

 

[SLUser11]

I suppose not, but it's hard to imagine as Winged Scapula mentioned. Maybe it's because both she trained and I'm wrapping up my training in the Northeast, where autonomy isn't so tangible as it is in the South or Midwest (?).

You and I got in an argument a while back about a similar topic. I guess what frustrates me is that people in the Northeast have a certain amount of tunnel vision, and tend to assume that their experience is "the way it is," when in fact there are plenty of programs in other areas of the country that are quite different.

e.g. "There's no such thing as a compliant 80 hour rule."---Follow that up with "if there is, then the residents are weak/teaching suffers."

e.g. "All ER docs suck, IM docs suck, etc"

e.g. "No intern is doing (insert procedure here). They just think they are."

You guys often assume that anything other than what you're used to is either inaccurate or inferior, when in fact you couldn't be more wrong. Of course, I don't completely blame you for that, as you're a product of your environment, and are basically regurgitating what you've been told since the first day of med school.


Now I have a question for both you and WS: You have stated that the "coolest cases" the interns have just described were really glorified first assistant roles, and yet you also admit you lacked autonomy as residents. When you participated in these cases as juniors residents, did you count them as surgeon junior or first assist?

 

[Winged Scapula]

You and I got in an argument a while back about a similar topic. I guess what frustrates me is that people in the Northeast have a certain amount of tunnel vision, and tend to assume that their experience is "the way it is," when in fact there are plenty of programs in other areas of the country that are quite different.

e.g. "There's no such thing as a compliant 80 hour rule."---Follow that up with "if there is, then the residents are weak/teaching suffers."

e.g. "All ER docs suck, IM docs suck, etc"

e.g. "No intern is doing (insert procedure here). They just think they are."

You guys often assume that anything other than what you're used to is either inaccurate or inferior, when in fact you couldn't be more wrong. Of course, I don't completely blame you for that, as you're a product of your environment, and are basically regurgitating what you've been told since the first day of med school.


Now I have a question for both you and WS: You have stated that the "coolest cases" the interns have just described were really glorified first assistant roles, and yet you also admit you lacked autonomy as residents. When you participated in these cases as juniors residents, did you count them as surgeon junior or first assist?

If I was doing 50% of the case, I coded them as surgeon junior. If I was essentially holding hook, closing the skin, running the sucker, doing a little Bovieing here and there, I counted it as First Assist. I actually coded nearly all my pediatric surgery cases as a Chief as First Assist because frankly that's what I was doing since the attendings were often double scrubbed for the big cases; the PD made me change it to Surgeon Chief.

It may very well be that interns are doing lap choles and tumor debulking. But I think it worth asking what people mean when they say they are "doing the case" because I have found it to be commonly misperceived. I find that hard to believe that they are "really" doing the case, but I have no interest in arguing because I am willing to admit that I might be wrong. But I am wrong in the NE and wrong here, because I don't see it done here either.

Rather than assume we are wrong because of our NE blinders (and that our experience is only right in the NE and everyplace else in the country is wonderful with interns doing Whipples and never going over 80 hrs), perhaps it might be just as valid an argument to say that what YOU are experiencing is NOT the norm. Who's to say?

 

[SLUser11]

If I was doing 50% of the case, I coded them as surgeon junior. If I was essentially holding hook, closing the skin, running the sucker, doing a little Bovieing here and there, I counted it as First Assist. I actually coded nearly all my pediatric surgery cases as a Chief as First Assist because frankly that's what I was doing since the attendings were often double scrubbed for the big cases; the PD made me change it to Surgeon Chief.

It may very well be that interns are doing lap choles and tumor debulking. But I think it worth asking what people mean when they say they are "doing the case" because I have found it to be commonly misperceived. I find that hard to believe that they are "really" doing the case, but I have no interest in arguing because I am willing to admit that I might be wrong. But I am wrong in the NE and wrong here, because I don't see it done here either.

Rather than assume we are wrong because of our NE blinders (and that our experience is only right in the NE and everyplace else in the country is wonderful with interns doing Whipples and never going over 80 hrs), perhaps it might be just as valid an argument to say that what YOU are experiencing is NOT the norm. Who's to say?

I agree with you for the most part, which is why I haven't contributed my coolest intern cases, because I coded almost all "cool" cases as first assist, since it's coolness to me was likely it's rareness among my caseload.

I'm not a big fan of the wordage "interns doing whipples" because that's not what I meant. What I'm saying is that a HAPPY MEDIUM exists. There are programs that ride the fence, giving benefits of both academic and community environments. However, traditionally when these types of programs have been brought up, many posters from the Northeast treat them like mythical forest creatures.

Word it how you want, but I've been reading posts on here for almost 4 years and I'm well-aware of the "Northeast blinders," and they are most definitely not mythical.

Where I am training is definitely not the norm, which is why I chose it. BUT, that is not to say that I don't recognize the faults in my own program. Specifically, I feel my training is subject to the politics of private surgical groups.

My post has been relatively fragmented and tangential, so I will end it soon. I respect your opinion, and even Castro's even if I have a hard time showing it. My last post was not meant to call you out, but just to illustrate that, as interns, you guys also felt like you were "doing the case," and then later realized your attendings' ability to do an entire case with the yankauer.

However, I get nervous that med students will come to this forum and suffer from its severe sample bias, and then this will compromise their ability to see their true options when it comes to residency. When I start to rant, it's usually with the somewhat disguised intention of letting the students know that they have a few more choices than they thought.

 

[sponch]

Wow, it all the sudden got real tense. Anyway, I guess the highlight of my year was doing a radical nephrectomy with a private urology attending. I did the whole thing... retroperitoneal dissection, exposing the hilum and ureter, taking them, and closing up. It was awesome. Of course, this would have never happened with the university faculty, but I was just in the right place at the right time.

 

[tussy]

I agree that "doing the case" is a bit of a stretch. Most interns would not be able to do any of these cases if the attending/fellow/senior wasn't helping, exposing, guiding, etc. I think anyone who thinks they are capable of doing any of these cases within their first year of residency just doesn't have enough experience to recognize the help they are being given.

However, it's incredibly cool as an intern to feel like you're doing a case and i like to give my residents that experience whenever possible, just like people did for me. It's the small carrott that keeps you going when intern life might otherwise be miserable. However, if my junior is getting too "cocky" it's nice to bring them back to reality by letting them try to really do the case; I let them and the clerk go and i just hang back making sure they don't do any real damage and when they get stuck/don't know how to expose or proceed then i step in and show them.

Surgery is fun.

 

[Blade28]

Wow, it all the sudden got real tense. Anyway, I guess the highlight of my year was doing a radical nephrectomy with a private urology attending. I did the whole thing... retroperitoneal dissection, exposing the hilum and ureter, taking them, and closing up. It was awesome. Of course, this would have never happened with the university faculty, but I was just in the right place at the right time.

Awesome! 👍

 

[Castro Viejo]

You and I got in an argument a while back about a similar topic. I guess what frustrates me is that people in the Northeast have a certain amount of tunnel vision, and tend to assume that their experience is "the way it is," when in fact there are plenty of programs in other areas of the country that are quite different.

Quite possible. And that's why I wrote what I wrote. I understand that resident autonomy in General Surgery can vary quite a bit from program to program and, moreso, from region to region. My friends in the South say it's great. My friends up here in the Northeast (New England/Mid Atlantic states) generally say it sucks mooseballs. I happen to think my own program is pretty good with resident autonomy, but it certainly isn't the norm for the New York area programs and not generally for the lovely Northeast.

You guys often assume that anything other than what you're used to is either inaccurate or inferior, when in fact you couldn't be more wrong. Of course, I don't completely blame you for that, as you're a product of your environment, and are basically regurgitating what you've been told since the first day of med school.

Hmmm... I don't quite understand why you believe you are the clearinghouse on opinion in this forum.

Now I have a question for both you and WS: You have stated that the "coolest cases" the interns have just described were really glorified first assistant roles, and yet you also admit you lacked autonomy as residents. When you participated in these cases as juniors residents, did you count them as surgeon junior or first assist?

Perhaps your general dislike for my posts is the root cause of all this.

I don't believe I accused any of the interns posting that they were glorified first assistants. I just found it "hard to imagine" that an intern would be doing an ALND. Now, if you believe that that excludes the realm of possibility in my mind, then I'm sorry, but you should read the post more carefully.

In answer to your question, as Winged Scapula noted, I listed myself as Surgeon Junior when I performed 50% or more of the case. If I believed I got nothing from the case, held hook, became the Bovie scraper, or the sucker man, then I didn't log the case at all. My PD also did not want us to code too many First Assists.

So I didn't log the lap choles that I "did" as an intern when it was the attending who splayed the gall bladder out for me and I hooked it with my right, while watching it with the camera in my left. That's NOT doing a lap chole, in my opinion.

As I've stated in the past with regard to my program, it has a little more autonomy than the typical program that I know here in New York. Chief Residents can start cases. Chief Residents can do cases without attending supervision. Attendings must be present for the "critical portion" of the case. Chief Residents have operating room privileges in trauma and emergent situations. In my program common, bread-and-butter cases are done by a Chief Resident and an intern who wants someone to "take him (or her) through it."

Prior to the Chief year all residents, even R4s, need an attending opposite them in the OR. In those cases sometimes even an R4 will be muscled out of doing the case because it's Friday afternoon/evening or the attending has to rush out to get to the office. It sucks, but that's life in the Northeast.

 

[Castro Viejo]

Wow, it all the sudden got real tense.

Yeah. He tends to do that...

 

[Castro Viejo]

However, I get nervous that med students will come to this forum and suffer from its severe sample bias, and then this will compromise their ability to see their true options when it comes to residency. When I start to rant, it's usually with the somewhat disguised intention of letting the students know that they have a few more choices than they thought.

Martyrdom is cool.

 

[dpmd]

I have been wondering how to define my participation in many of the cases I have scrubbed on this year (about 200 so far). Some were easy to figure out (I+D's or lumps and bumps where I did everything without any significant verbal instruction). But what about the cases where I did the dissection, but was verbally guided by the attending? Then there are the unique things like the free flaps where I was walked though the dissection up until the working with the pedicle, then closed the donor site on my own (the iliac crest osteocutaneous flap we did was particularly cool with the multi-layered closure) before heading down to help inset the flap. I wouldn't say I did the flap, but first assistant seems inadequate to distinguish this from simply holding a retractor and suturing a little.

We scrub a lot of subspecialty stuff where it is just the intern and the attending. Sometimes I am just an extra pair of hands, but other times I am more active (drilling and screwing, being walked through one side of a bilateral case, etc). I have been told before that if it is just me and the attending I should code it as surgeon junior, but it doesn't seem right if I just open and close.

Any thoughts?