How can you tell when a student is "wrong" for surgery?

[odyssey2]

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Are there any specific personality traits or "tells" that let you know that a student would never survive a surgical residency? How do you deal with them when they're on their rotations?

 

[Dr.LeoSpaceman]

Are there any specific personality traits or "tells" that let you know that a student would never survive a surgical residency? How do you deal with them when they're on their rotations?

In the words of Justice Potter Stewart: "I know it when I see it."

And I think you would need to specificy whether this person is one whom is interested in pursuing surgery. If they aren't, then it's about finding the information/tasks that might be relevant to their actual interests. If they are interested in surgery, it's a bit more challenging. You have to "coach 'em up" as much as possible, but make it clear to the clerkship director that there may need to be a faculty-level discussion with them about their career plans.

But to answer your question, the main thing for me is of I get the sense that people aren't self-directed and/or internally motivated. There's a lot less handholding in surgical residencies, and I do think it takes a specific personality to succeed in that environment.

 

[odyssey2]

In the words of Justice Potter Stewart: "I know it when I see it."

And I think you would need to specificy whether this person is one whom is interested in pursuing surgery. If they aren't, then it's about finding the information/tasks that might be relevant to their actual interests. If they are interested in surgery, it's a bit more challenging. You have to "coach 'em up" as much as possible, but make it clear to the clerkship director that there may need to be a faculty-level discussion with them about their career plans.

But to answer your question, the main thing for me is of I get the sense that people aren't self-directed and/or internally motivated. There's a lot less handholding in surgical residencies, and I do think it takes a specific personality to succeed in that environment.

I suppose I meant someone who's interested in surgery but just doesn't seem to have what it takes, since that's where the problem comes in.

 

[deleted480308]

I suppose I meant someone who's interested in surgery but just doesn't seem to have what it takes, since that's where the problem comes in.

More people don’t have what it takes to match than don’t have what it takes to do the work of a surgeon

a lot get into it and decide they don’t actually want it which is a different discussion

 

[LucidSplash]

I suppose I meant someone who's interested in surgery but just doesn't seem to have what it takes, since that's where the problem comes in.

Agreed that most of the time people 1) self-select and 2) there are a lot of people who have what it takes but want something else.

I have seen a couple students over the years that I was either a) surprised after their rotation when they told me they were interested in surgery or b) I had real concern that they would ultimately struggle in the field.

In the first case I had a student who spent an entire trauma rotation looking up medical zebras that might explain small laboratory abnormalities in the patients and didn’t seem interested in the actual trauma care at all despite attempts at redirection. Bright guy but I pegged him as destined for medicine. Later came to me for advice in matching into surgery. I gave him the best advice I could while tacitly telling him to make sure it was the right field for him. He matched but ended up in anesthesia after a couple of years.

In the 2nd case I had a student who seemed to struggle with grasping the importance of the basics of the ABCs of trauma during an actual trauma. Difficulty with identifying the basic symptom patterns of gall bladder. Would get hung up on one vital sign or lab value that didn’t match up with a basic easy diagnosis which would prevent them from connecting the dots despite prompting. The student could rattle off all the appropriate info during a teaching session. Seemed very bright. But when placed into a situation with real patients and not textbook or practice questions, really struggled. Similarly, this student matched, but left to pursue something else after a year.

These are extreme cases that I remember. But honestly a lot who end up not choosing surgery could do surgery. Like most people can make it through military boot camp I suppose, but choose not to join the military.

Most importantly, it is NEVER about the “hands” of a student. This is the least important part of surgery. You just want to see that a student interested in surgery has practiced a bit and takes pointers on their suturing/tying.

 

[WedgeDawg]

I’m a very junior resident but the upper level residents I’ve seen be the most effective are those that demonstrate effective time management, the ability to triage tasks appropriately, being intrinsically driven and self-directed, the willingness to support the team and back up their co-residents, efficiency, strong communications skills, people management skills, and situational awareness. This all translates to being an effective surgical resident which means more time in the OR which ultimately means being a better surgeon. I’ve seen some sub-Is and 3rd years that’s have many of these qualities and some that don’t. People from both of these groups have successfully matched surgical fields, but I know which ones I’d rather have as co-residents and it’s not even close.

 

[WinslowPringle]

1) Desire - do they want to do surgery? I don't mean "Oh, yeah, being a surgeon would be cool" but "I have never seen anything so awesome as that [trauma-ex lap] [splenectomy] [gallbag] [etc.] and I *have* to be able to do it."
2) Drive - are they willing to do what it takes to be a good surgeon? This is more work for some than for others - more reading, more knot tying practice, more reps. This is also thought of as 'grit' or 'tenacity'. Surgeons, in general, are tenacious.
3) Digestion - surgeons have to take all this disparate information and boil it down into "Do I operate or not?" That can be really hard. You can't be chasing down every other possibility for why the patient is hypotensive after that MVC (although you have to quickly consider and discard the other reasons) but get that they're bleeding and get in there and stop it. This is the 'getting it.' This comes through practice and seeing the same scenarios over again and it can largely be taught - but sometimes not.
4) Digits - can you learn to do the mechanics? Pretty much every body with an intact cerebellar system and two hands and maybe a minimum of six fingers or so can learn the mechanics. Some will learn it easier, some will be better, but just about everyone can get the maneuvers down to be a safe surgeon.

The first two are the things that cull the most people. You have to really want it and be willing to work in sometimes pretty not great circumstances to get there. I've had a few medical students who said they wanted to be surgeons, but they were the first ones to leave and didn't want to stay for that extra case. Obviously, work life balance is important and being a med student sucks because you can't see anything, but I've talked to those few M3 med students about what residency is like and ultimately they went on to a non-surgical residency.

I have met one general surgery resident over intern year who just didn't get it. She was getting better with a lot of intensive coaching, lots of feedback from attendings and upper-levels, but it was a pretty brutal process. Her residency isn't done yet; will have to see how it goes.

There were one or two medical students who (fortunately) didn't want to do surgery due to a congenital malformation that led to insufficient manual control. Not something that current prostheses can overcome at this point, but maybe one day...

 

[VisionaryTics]

I think the people that really struggle are those that just can't deal with surgical learning curve.

Mistakes are right there in front of you, every day. You break a suture when tying down a knot? Attending, fellow, med student, scrub tech, etc all watch it happen. When it happens the first time your face turns red and you swear under your breath.

Extrapolate that throughout surgical training. You'll screw up wound evaluation and miss an infection that turns into a disaster. You'll injure a nerve and patient will live with that (temporarily or permanently). You'll offer a huge operation to a patient who has a positive margin and recurs of their cancer less than a month after and has a fast, painful, horrible death.

Being a surgical trainee and then a surgeon is about stomaching that **** again and again and again and again and pushing forward to do better.

Residents that I have seen who left surgery struggled with the above.

 

[Detective SnowBucket]

How can you tell?
Can they yell like an attending?
Can you bench like one?

 

[odyssey2]

On a related note, how do you deal with students not going into surgery who are overwhelmingly anxious about the OR and anything related to operating/clearly don't want to be involved in suturing/knot tying etc? Do you try to get them more comfortable or do you read the writing on the wall and stop getting them involved?

 

[LucidSplash]

On a related note, how do you deal with students not going into surgery who are overwhelmingly anxious about the OR and anything related to operating/clearly don't want to be involved in suturing/knot tying etc? Do you try to get them more comfortable or do you read the writing on the wall and stop getting them involved?

I try to teach them what they need to know for whatever specialty they think they might be interested in.

As an example, most FM docs do basic lac repair and suture removal in their office so it’s helpful to get some of that experience. Also, they are frequently the first person that a patient will ask about surgery, so it is helpful to them if they know the basics of what goes on for the most common cases (gallbag, appy, colectomy and colostomy, PEG tube, trach, etc) and what some of the common complications are. Additionally, they need to know the workup as, again, they are typically the first line for many of these complaints (eg the difference between symptomatic cholelithiasis and acute cholecystitis); which needs an outpatient US and which needs to go to the ED. As vascular, when I had students as a fellow, I would try to teach them the basics of acute vs chronic limb ischemia, how to do a decent pulse exam and do a manual ABI, and that the first line of treatment for varicose veins is usually compression socks. Now that I am in practice, there is definitely a need for this kind of education at the basic level, just based on the referrals I get. I’m happy to help the patient but a lot of the time they go years with issues before someone refers them and just these simple things could get patients help a lot sooner

Much of the shelf exam is the medical management of surgical patients. I know the perception is that we are just operative technicians, but there is a lot more to learn and a lot of crossover.

Believe it or not we know that not everyone wants to be a surgeon. But we think some basic knowlege about surgery is helpful to most students because most fields will end up interacting with surgeons. Somewhat selfishly to our benefit, but definitely to the patients’, a smart IM or FM doc who knows this stuff is awesome to work with from a surgeon’s perspective.

 

[WinslowPringle]

On a related note, how do you deal with students not going into surgery who are overwhelmingly anxious about the OR and anything related to operating/clearly don't want to be involved in suturing/knot tying etc? Do you try to get them more comfortable or do you read the writing on the wall and stop getting them involved?

I've done both depending on the student, rotation, patients, etc. and have had really variable results.

One person who had no business ever stepping foot in an OR, I tried to take on consults, show how to suture, took on a personal tour of the operative area twice to calm nerves, showed several times how to scrub and gown, praised them to the scrubs, and tried to highlight "Hey, I know you don't want to do surgery, but these things are great for you to know going into XYZ field for how/when to consult us." Really tried to be nice and help with the anxiety....and for my troubles got called a big fat meanie by that med student. Another med student with the same demeanor really appreciated the extra time and teaching, wrote a thank you note etc. *Shrug*

One med student that was pretty verbal about never doing surgery, I told them "Cool. You're an adult and paying for this. Come when you want, leave when you want. See what you can. Let me know if you have any questions. Don't worry about rounding. I won't evaluate you." They really liked this approach and spent their time studying for boards. Another med student said they weren't interested and I said the exact same thing, bought them coffee and told them to enjoy themselves; and the med student came to a few cases and deliberately tried to pick all the cases where I wasn't because the student was intimidated. *Shrug*.

Ideally, I try to highlight salient points and tailor for what they are interested in; but that's tough if they have no clue other than 'not surgery.' I think how to hold a needle driver and how to place an interrupted suture is a basic skill that I try to teach. Try to cover the main complications of the big surgeries and the anatomy when we're looking at it. And try to say "here is how and when to consult us."

 

[giguerex35]

anytime a premed says ortho or bust theyre not surgery material

 

[WedgeDawg]

A lot of good surgeon educators in this thread. Keep it up guys, interactions and mentorship like that is a big part of why many of us became surgeons.

 

[TypeADissection]

This is a tough issue because you're taking people who have rarely ever failed in their lives and then telling them that this thing that they really want to do, isn't for them. Hard conversation to have regardless of who the student is. There are a couple of red flags that get me concerned (how they're numbered does not indicate order of importance):

1. They can't tie a basic knot.
- I know this may seem like a controversial point but I knew I wanted to be a surgeon before I stepped foot in med school. It took almost nothing for me to go on YouTube and learn how to tie two-handed and one-handed knots. I got good at learning how to do subcuticulars because that was going to be my primary job as a student. In my experience when I see an intern come onto the service and they can't tie a knot I start to get worried because there are so many other things that they need to learn how to do outside of the OR that I always figured this base should've already been covered when they had ample time as students. I also haven't seen interns coming in with bad hands and suddenly get great hands over the course of their residency. Usually bad interns turn into either bad residents or mediocre ones at best. The good interns are good from day one and it's so obvious they have their s**t together and that didn't happen just because they got a long white coat, they were good way before then. Time in the OR isn't enough in my opinion, there needs to be concerted thought and time spent outside of the OR on improving skills. Once again, this may cause some debate but it's just my opinion.

2. They miss the gimmes in general surgery (Hinchey classification, hernia anatomy, appendicitis management, basic gallbag ****, etc).
- You can't tell me you want to be a surgeon and then when I ask about the 3-components of a Henri Hartmann you stare at me with a blank face. It's fine if you can't really read the CT, that's what we're here for. But if we're doing a hernia and I ask direct vs indirect and you can't tell me, that's a problem of preparation and now I question your commitment to this.

3. They're late.
- I give everybody a mulligan because life happens. But you can't be coming in late every single day or unprepared and then wonder why I question your ability to be a surgeon.

4. They have an inability to self-evaluate.
- This is gonna sound mean but some kids just don't know how bad they are and when faced with constructive criticism just can't take it. Somewhere along the way, multiple people failed these kids by not helping them realize that they're not perfect and that we all have areas to improve in.

These are the main things that come to mind but I think it's necessary to say something. I think the worst thing we can do is take people who are incapable of self-reflection, have poor surgical technique and judgment, can't handle pressure and then just push them through residency. The real world doesn't care about any of this and at some point reality will come in the form of a lawsuit or hospitals pushing them out/not renewing contracts because they're just bad. And now what? They're 5-7 years invested in a field they were ill-suited for from the very beginning. Pull the band-aid quickly and tell them they're probably a better fit in a different field. If they ignore wise counsel and decide to go into surgery regardless, well that's on them but at least we tried. And that's all we can do. Cheers.

 

[neriticzone]

Just a med student chiming in. One thing I appreciate when being pimped is when the attending asks me “tell me about x” where x is the disease or whatever. Gives me the chance to show I read, and also somewhat reduces the burn when I get their other questions wrong lol.

 

[HighPriest]

3-components of a Henri Hartmann

He was French.
He was a Surgeon.
He's dead now.

 

[HighPriest]

A student has to be interested and motivated. Most of what has been said already. They have to come prepared, they have to demonstrate interest. I've seen a couple of med students who may very well have been interested in (in my case) ENT, but they certainly seemed like they weren't at the moment. It's possible that's just a personality issue, but honestly if you seem bored and disinterested while you're on service I have to assume you'll be bored and disinterested as an ENT doc. I honestly don't expect students to be able to answer every question I ask. But as mentioned above, they have to be able to demonstrate a rudimentary understanding of the disease processes and treatments that we're currently treating. A lot of med students seem to think this means that they have to know what I know even though I'm board certified and they're a student. Not at all. It's not as much about the knowledge base as it is about the ability to learn and prepare. I expect that as I ask questions, they'll eventually be unable to answer them. I should probably know more than they do. It certainly helps to stratify the greats from the goods (and the mediocre and poor) students depending upon how detailed of an understanding they were able to generation overnight. So the questions are supposed to be a gauntlet that you eventually fail, but as a student you probably shouldn't trip right out of the gate because that just tells me you weren't reading (and are therefore bored and disinterested). Showing up late multiply means you shouldn't be a doctor, surgeon or otherwise. Get your $#!t together. You can't want it more than anything and also not care enough to set your alarm on time. If it's a one-off, and there's a good reason, I'm pretty forgiving.

Self-evaluation: agree completely. I think you have to have some degree of personal insight. Especially when you're out of residency and potentially on your own. You have to know when something goes wrong whether it was bad luck, your fault, or a combination. You have to be able to dissect a situation and determine where you need improvement. You have to be able to know when it's time to go to a course or do some more reading on a subject, and when to get back up to date on the literature. If you can't see your own strengths and weaknesses, you're going to have a bad time. And so are your patients. Nobody has complete internal transparency, but if you can't learn and grow as a med student (where it's pretty easy to know when you're off kilter because someone is literally telling you that you are), then you're going to be a bad surgeon.

 

[HighPriest]

He was French.
He was a Surgeon.
He's dead now.

BTW these three components work for an ASTOUNDING number of general surgery procedures. It's amazing how often this is accurate, so put that in your back pocket. Unless the name sounds German, then guess that he was German.

 

[argama]

This is a tough issue because you're taking people who have rarely ever failed in their lives and then telling them that this thing that they really want to do, isn't for them. Hard conversation to have regardless of who the student is. There are a couple of red flags that get me concerned (how they're numbered does not indicate order of importance):

1. They can't tie a basic knot.
- I know this may seem like a controversial point but I knew I wanted to be a surgeon before I stepped foot in med school. It took almost nothing for me to go on YouTube and learn how to tie two-handed and one-handed knots. I got good at learning how to do subcuticulars because that was going to be my primary job as a student. In my experience when I see an intern come onto the service and they can't tie a knot I start to get worried because there are so many other things that they need to learn how to do outside of the OR that I always figured this base should've already been covered when they had ample time as students. I also haven't seen interns coming in with bad hands and suddenly get great hands over the course of their residency. Usually bad interns turn into either bad residents or mediocre ones at best. The good interns are good from day one and it's so obvious they have their s**t together and that didn't happen just because they got a long white coat, they were good way before then. Time in the OR isn't enough in my opinion, there needs to be concerted thought and time spent outside of the OR on improving skills. Once again, this may cause some debate but it's just my opinion.

2. They miss the gimmes in general surgery (Hinchey classification, hernia anatomy, appendicitis management, basic gallbag ****, etc).
- You can't tell me you want to be a surgeon and then when I ask about the 3-components of a Henri Hartmann you stare at me with a blank face. It's fine if you can't really read the CT, that's what we're here for. But if we're doing a hernia and I ask direct vs indirect and you can't tell me, that's a problem of preparation and now I question your commitment to this.

3. They're late.
- I give everybody a mulligan because life happens. But you can't be coming in late every single day or unprepared and then wonder why I question your ability to be a surgeon.

4. They have an inability to self-evaluate.
- This is gonna sound mean but some kids just don't know how bad they are and when faced with constructive criticism just can't take it. Somewhere along the way, multiple people failed these kids by not helping them realize that they're not perfect and that we all have areas to improve in.

These are the main things that come to mind but I think it's necessary to say something. I think the worst thing we can do is take people who are incapable of self-reflection, have poor surgical technique and judgment, can't handle pressure and then just push them through residency. The real world doesn't care about any of this and at some point reality will come in the form of a lawsuit or hospitals pushing them out/not renewing contracts because they're just bad. And now what? They're 5-7 years invested in a field they were ill-suited for from the very beginning. Pull the band-aid quickly and tell them they're probably a better fit in a different field. If they ignore wise counsel and decide to go into surgery regardless, well that's on them but at least we tried. And that's all we can do. Cheers.

Hmm I will agree with most of what you said. I admit as a general surgery resident, when I was a student I was not great at tying knots (but I could do it!), but I found as a student, closing running subcuticular (that was acceptable) was difficult to practice. All the suture boards I had were too poor quality...they would rip and tear as you sutured. There were some decent ones I saw that was about $250-300 and I always entertained buying that until I saw my bank account. Some mentioned buying a pig's foot or something but honestly I did not know where to find said thing or buy it just for a 1x practice session to close running subq. Nothing really can emulate human tissue. Now I can do all those fine, but when I was a student, I've had residents tell me if a student couldnt close running subcuticular, they were not surgery material. Obviously, that is not true.

The rest though I agree!

 

[mestielest]

On the other hand, I saw a lot of people who should have never been on any part of the surgery... Some of them are professors etc.

 

[Dr.LeoSpaceman]

Time in the OR isn't enough in my opinion, there needs to be concerted thought and time spent outside of the OR on improving skills. Once again, this may cause some debate but it's just my opinion.

This probably goes beyond the scope of the original topic, but I agree and I think it's probably related to a bigger picture item. Though I also agree with others that not being able to tie or be proficient at other technical skills shouldn't necessarily disqualify someone, as you can teach most anyone to tie or suture with enough practice.

But what isn't necessarily a guarantee is being able to teach someone how to conceptualize and "setup" the procedure. Yes most people can memorize step 1 to X of a given procedure. The issue becomes people who can't seem to understand how those steps fit together as a whole. If you don't know why you're doing a particular step, it leads to problems when things aren't going according to plan.

So perhaps knot tying or other simple skills are surrogates for that kind of surgical understanding. It was relatively easy for me to learn how to tie and suture (with practice) because for one reason or another I could "see" how those things were working. It's not just about "this is a square knot", but "why is this a square knot?" I suspect it's the same for most others.

The question then becomes how we identify these people or measure these skills in students. I don't think we have mechanisms to do that now, which can lead to some difficult situations when people hit later years of residency.

 

[HighPriest]

I think, also, having a lot of difficulty conceptualizing three dimensional spaces is a bit of a problem. We would have discussions in residency in our academic sections all of the time wherein we would talk about what the relation of one structure was to another. Such as:’the relationship between the hypoglossal nerve and the submandibular gland, or the location of different ethmoidal cells to one another, etc. Being able to picture these things in your mind is important I think, and just memorizing relationships without being able to form a mental picture is not as helpful. Might not be something you’d wash someone out for, but there are definitely applicants who just can’t make 3D mental pictures.

 

[Mr Cookie Pants]

I've done both depending on the student, rotation, patients, etc. and have had really variable results.

One person who had no business ever stepping foot in an OR, I tried to take on consults, show how to suture, took on a personal tour of the operative area twice to calm nerves, showed several times how to scrub and gown, praised them to the scrubs, and tried to highlight "Hey, I know you don't want to do surgery, but these things are great for you to know going into XYZ field for how/when to consult us." Really tried to be nice and help with the anxiety....and for my troubles got called a big fat meanie by that med student. Another med student with the same demeanor really appreciated the extra time and teaching, wrote a thank you note etc. *Shrug*

One med student that was pretty verbal about never doing surgery, I told them "Cool. You're an adult and paying for this. Come when you want, leave when you want. See what you can. Let me know if you have any questions. Don't worry about rounding. I won't evaluate you." They really liked this approach and spent their time studying for boards. Another med student said they weren't interested and I said the exact same thing, bought them coffee and told them to enjoy themselves; and the med student came to a few cases and deliberately tried to pick all the cases where I wasn't because the student was intimidated. *Shrug*.

Ideally, I try to highlight salient points and tailor for what they are interested in; but that's tough if they have no clue other than 'not surgery.' I think how to hold a needle driver and how to place an interrupted suture is a basic skill that I try to teach. Try to cover the main complications of the big surgeries and the anatomy when we're looking at it. And try to say "here is how and when to consult us."

I tried that, but at the end of the day, when I was on Psych, I still had to do my **** despite being pre surgery. I tell students this, its an intro to professionalism. So I have switched now and do more of a 'as a ER doc, heres why your consults suck, remember this' kinda thing (CT) or just overall say heres the things you need to know about CT surgery for boards and life.

At the end of the day, med students giving you a bad review doesn't matter one iota. I used to think it did, but as long as theres no personal or professional violation, you can just tell the medical school the numerous transgressions you didnt evaluate. They usually know who the bad apples are.

This is a tough issue because you're taking people who have rarely ever failed in their lives and then telling them that this thing that they really want to do, isn't for them. Hard conversation to have regardless of who the student is. There are a couple of red flags that get me concerned (how they're numbered does not indicate order of importance):

1. They can't tie a basic knot.
- I know this may seem like a controversial point but I knew I wanted to be a surgeon before I stepped foot in med school. It took almost nothing for me to go on YouTube and learn how to tie two-handed and one-handed knots. I got good at learning how to do subcuticulars because that was going to be my primary job as a student. In my experience when I see an intern come onto the service and they can't tie a knot I start to get worried because there are so many other things that they need to learn how to do outside of the OR that I always figured this base should've already been covered when they had ample time as students. I also haven't seen interns coming in with bad hands and suddenly get great hands over the course of their residency. Usually bad interns turn into either bad residents or mediocre ones at best. The good interns are good from day one and it's so obvious they have their s**t together and that didn't happen just because they got a long white coat, they were good way before then. Time in the OR isn't enough in my opinion, there needs to be concerted thought and time spent outside of the OR on improving skills. Once again, this may cause some debate but it's just my opinion.

2. They miss the gimmes in general surgery (Hinchey classification, hernia anatomy, appendicitis management, basic gallbag ****, etc).
- You can't tell me you want to be a surgeon and then when I ask about the 3-components of a Henri Hartmann you stare at me with a blank face. It's fine if you can't really read the CT, that's what we're here for. But if we're doing a hernia and I ask direct vs indirect and you can't tell me, that's a problem of preparation and now I question your commitment to this.

3. They're late.
- I give everybody a mulligan because life happens. But you can't be coming in late every single day or unprepared and then wonder why I question your ability to be a surgeon.

4. They have an inability to self-evaluate.
- This is gonna sound mean but some kids just don't know how bad they are and when faced with constructive criticism just can't take it. Somewhere along the way, multiple people failed these kids by not helping them realize that they're not perfect and that we all have areas to improve in.

These are the main things that come to mind but I think it's necessary to say something. I think the worst thing we can do is take people who are incapable of self-reflection, have poor surgical technique and judgment, can't handle pressure and then just push them through residency. The real world doesn't care about any of this and at some point reality will come in the form of a lawsuit or hospitals pushing them out/not renewing contracts because they're just bad. And now what? They're 5-7 years invested in a field they were ill-suited for from the very beginning. Pull the band-aid quickly and tell them they're probably a better fit in a different field. If they ignore wise counsel and decide to go into surgery regardless, well that's on them but at least we tried. And that's all we can do. Cheers.

I had a student that was dead set on GS and #1,2 and 4 was a problem.For the first time ever with a student, I pulled him aside and said, I really don't think you're cut out for this and gave some examples. He said thank you and still applied for the match and went unmatched. (not even a prelim spot out of a US med school).

Nowadays with med school being so different (work hours, no call, lectures) vs when I was a MS3 in 2010 (still call, med students got paged, paper notes and orders) I just try to lay out the realities of the field and make sure students are prepared for the commitment of surgery. Then I tell them how much I love my life, field of work, future salary, that we get to listen to music all day and wear pajamas and cut people open.

 

[TypeADissection]

I had a student that was dead set on GS and #1,2 and 4 was a problem.For the first time ever with a student, I pulled him aside and said, I really don't think you're cut out for this and gave some examples. He said thank you and still applied for the match and went unmatched. (not even a prelim spot out of a US med school).

Nowadays with med school being so different (work hours, no call, lectures) vs when I was a MS3 in 2010 (still call, med students got paged, paper notes and orders) I just try to lay out the realities of the field and make sure students are prepared for the commitment of surgery. Then I tell them how much I love my life, field of work, future salary, that we get to listen to music all day and wear pajamas and cut people open.

I'm in my mid-30s but I really feel like the old curmudgeon who shakes his fist at kids and yells, "Get off my lawn!" The level of entitlement that I have seen in med students and junior residents is astounding to me at times. I'm talking about med students who openly complained to the GME and shortly afterwards we get a written statement that we have to sign saying that we will not pimp, or make them pre-round, or ask them to stay late for a cool case or anything that is deemed "bullying" and thus incongruent with healthy medical education. And then some of the students match and as interns are filing complaints against the rotation because they were not allowed to scrub the open thoraco or do a carotid. Instead, they spent the rotation doing amps, catheters and closing bypass incisions. I don't understand this at all. I'm a pretty chill dude and like to have fun and joke around in the OR, but as soon as I see this level of entitlement and laziness; I go from 0 to 100 on the anger scale. Of course, I don't say anything because that would be considered a violation of safe space.

Having said all this, this has really only been maybe 3-5 residents that I've worked with and <10 med students. Most of the residents I've worked with in my own program and in fellowship have been exceptional and have definitely been impressed with many of the med students that have rotated through. But I do think there is a chasm in self-reflection in some individuals which makes it very difficult to counsel them appropriately.

 

[Dr.LeoSpaceman]

The level of entitlement that I have seen in med students and junior residents is astounding to me at times.

We're probably within the same surgical "generation", and this is something with which I struggle. With the focus on burnout, resilience, the SECOND trial, etc. it seems that many have decided that these issues can be altered by programatic/cultural changes. While these no doubt play a significant role, it's hard to discount that there are some individual characteristics that contribute.

I've been fortunate enough to make it through relatively unscathed. I attribute this to a variety of things including awesome family support, along with great faculty and co-residents. But I'd also like to believe some of it has to do with how I've approached this period of my life. When interns and medical students ask me how I did it, I tell them "don't make any plans for the next 5-7 years". That's obviously hyperbole, but I try to make the point that for this defined portion of your life the primary concern is to learnimg how to practice independently. If you're always worried about getting to [insert personal engagement], you will not only miss out of that experience but also quickly become miserable. There needs to be balance, but "balance" has seemingly become code for "we shouldn't have to exert ourselves".

For example, this is my weekend "off", but I still spent about 45 minutes looking through charts each day, and making a few patient calls to people with upcoming surgeries. This is neither necessary or expected, but it makes me feel better, and I hope the patients feel the same. Unfortunately I know a handful of residents who would start talks of calling the program director if there was any whiff of expectation that this is something you should do when you're off.

 

[TableMD]

Hi I'm a sports med/family doc and knew with 100% certainty that the OR was NOT for me, but I did my absolute best every day to pick up everything I could when spending time with surgeons. Maybe it's because Im an older/career changer, but looking at the totality of what the field demands is inspiring. When I do my nerve blocks, prolotherapy and other procedures, I try to channel the professionalism I appreciated in surgeons.

Anyone who leaves their surgery experience(s) empty handed is a fool.

I still remember my one-on-one surgical board style "case" at the end of my rotation and how I felt being able to answer the surgeon's questions and that was 8 years ago.

 

[SLUser11]

Are there any specific personality traits or "tells" that let you know that a student would never survive a surgical residency? How do you deal with them when they're on their rotations?

First of all, the literature shows clearly that, as educators, we are very bad at determining who is going to survive residency and make a great surgeon. Therefore, I have to swiftly invalidate everyone's opinion here, including my own.

Secondly, the technical abilities of a student, or any secondary marker of it like video games, etc, means almost nothing. Regardless of where they start, almost every chief resident is technically proficient and lies within 1 standard deviation of the mean. Additionally, technical abilities are nowhere near the most important part of a surgeon's job. Plenty of surgeons have "gifted hands" but don't make correct decisions, and can't troubleshoot problems well, and they are THE MOST dangerous because they don't have self-awareness.

If you want to do surgery, then almost certainly you are not "wrong for surgery." There are plenty of people who don't have an adequate work ethic, adequate hard drive, or adequate pressure under fire, but if you got into med school, you have the hard drive, and the rest is up to you, not the program director.

The secret to surgery is simpler than you think: hard work. There's no substitute. There's no magic pill. Hard work pays off.

Miss you guys. I'm glad to see SDN is holding strong.

SLUser

 

[LucidSplash]

First of all, the literature shows clearly that, as educators, we are very bad at determining who is going to survive residency and make a great surgeon. Therefore, I have to swiftly invalidate everyone's opinion here, including my own.

Secondly, the technical abilities of a student, or any secondary marker of it like video games, etc, means almost nothing. Regardless of where they start, almost every chief resident is technically proficient and lies within 1 standard deviation of the mean. Additionally, technical abilities are nowhere near the most important part of a surgeon's job. Plenty of surgeons have "gifted hands" but don't make correct decisions, and can't troubleshoot problems well, and they are THE MOST dangerous because they don't have self-awareness.

If you want to do surgery, then almost certainly you are not "wrong for surgery." There are plenty of people who don't have an adequate work ethic, adequate hard drive, or adequate pressure under fire, but if you got into med school, you have the hard drive, and the rest is up to you, not the program director.

The secret to surgery is simpler than you think: hard work. There's no substitute. There's no magic pill. Hard work pays off.

Miss you guys. I'm glad to see SDN is holding strong.

SLUser

Woah, blast from the past/its alive!!! Good to see you man.

 

[mestielest]

First of all, the literature shows clearly that, as educators, we are very bad at determining who is going to survive residency and make a great surgeon. Therefore, I have to swiftly invalidate everyone's opinion here, including my own.

Secondly, the technical abilities of a student, or any secondary marker of it like video games, etc, means almost nothing. Regardless of where they start, almost every chief resident is technically proficient and lies within 1 standard deviation of the mean. Additionally, technical abilities are nowhere near the most important part of a surgeon's job. Plenty of surgeons have "gifted hands" but don't make correct decisions, and can't troubleshoot problems well, and they are THE MOST dangerous because they don't have self-awareness.

If you want to do surgery, then almost certainly you are not "wrong for surgery." There are plenty of people who don't have an adequate work ethic, adequate hard drive, or adequate pressure under fire, but if you got into med school, you have the hard drive, and the rest is up to you, not the program director.

The secret to surgery is simpler than you think: hard work. There's no substitute. There's no magic pill. Hard work pays off.

Miss you guys. I'm glad to see SDN is holding strong.

SLUser

Exactly agree. In most of the situations, there is only one choice to do in an operation. So as surgeons, we are more technicians that magicians. The craft of the surgery lies in staying calm, learning from the available and well-grown knowledge, learning from experiences, being a compatible team member and company, and the most important to know what you should not do. Therefore, I think that the sensible one is more close to being a good surgeon than the magic-kid. To be a great-surgeon, in our timeline, the trick is not performing surgery but carrying out research. Completely different than the roots of surgery.

 

[LucidSplash]

In most of the situations, there is only one choice to do in an operation.

One caveat: does not apply in a lot of vascular surgery.

 

[HighPriest]

Yeah I don’t entirely agree. What makes a good physician of any type is having the knowledge base, experience, and composure to know what to do (and to do it) when things go wrong. If things went well all of the time, anyone could do surgery. The question is; can you predict that person?
We may be bad at picking “good” candidates, but that of course depends upon how these studies define a successful surgeon. It also depends upon what they defined as a poor candidate. Some of the things mentioned above aren’t really calculable, meaning that they might make a good surgeon but you often don’t know if a candidate possesses those skills until you know.

As a patient, I appreciate very much when a surgeon does research and progresses the field. We wouldn’t be where we are without that. But also as a patient: I don’t care even in the slightest if my surgeon does research. I just want to come out from under the knife alive and without complications.

I don’t necessarily think that it makes sense to throw things to the wind because “no one knows” what makes a student a good surgeon. Nor do I agree that anyone who made it through med school has the chops. I have certainly met relatively lazy And disinterested med students. I’ve also met plenty of people who were more driven and smarter than many med students, who never went to medical school.

And finally: a number of the surgeries I do have more than one choice. I get the concept: sometimes things are very algorithmic. Not always.

Just my experience.

 

[Dr.LeoSpaceman]

One caveat: does not apply in a lot of vascular surgery.

I don't think it applies to anything more complex than "lumps and bumps". Many people can memorize the steps of an operation. Making it happen (safely) is a different story.

I don’t necessarily think that it makes sense to throw things to the wind because “no one knows” what makes a student a good surgeon.

I'm with you here. I think that suggests we aren't good at identifying (or choose not to focus on) the relevant qualities. And as long as we're focusing on board scores, how many publications you have, or whom can answer the most pimp questions in the OR, that's almost certainly the case. We can't identify these students because it's impossible, but because the current paradigm for medical education isn't necessarily built to meet that goal.

 

[HighPriest]

I don't think it applies to anything more complex than "lumps and bumps". Many people can memorize the steps of an operation. Making it happen (safely) is a different story.



I'm with you here. I think that suggests we aren't good at identifying (or choose not to focus on) the relevant qualities. And as long as we're focusing on board scores, how many publications you have, or whom can answer the most pimp questions in the OR, that's almost certainly the case. We can't identify these students because it's impossible, but because the current paradigm for medical education isn't necessarily built to meet that goal.

Exactly

 

[LucidSplash]

I don't think it applies to anything more complex than "lumps and bumps". Many people can memorize the steps of an operation. Making it happen (safely) is a different story.



I'm with you here. I think that suggests we aren't good at identifying (or choose not to focus on) the relevant qualities. And as long as we're focusing on board scores, how many publications you have, or whom can answer the most pimp questions in the OR, that's almost certainly the case. We can't identify these students because it's impossible, but because the current paradigm for medical education isn't necessarily built to meet that goal.

I guess I was thinking from the perspective of general surgery, since I’m also technically a general surgeon even though I don’t practice that side.

There’s generally very limited “correct” options for dealing with a perforated viscous, abdominal cancer, trauma, breast, etc.

One of the reasons I liked vascular was that there are so many ways to skin a cat.

Not putting anyone/any other specialties down. Just I guess my own bias of why I chose my particular specialty based staying in general surgery (which I also enjoyed, but not as much).

 

[mikeGR]

I guess I was thinking from the perspective of general surgery, since I’m also technically a general surgeon even though I don’t practice that side.

There’s generally very limited “correct” options for dealing with a perforated viscous, abdominal cancer, trauma, breast, etc.

One of the reasons I liked vascular was that there are so many ways to skin a cat.

Not putting anyone/any other specialties down. Just I guess my own bias of why I chose my particular specialty based staying in general surgery (which I also enjoyed, but not as much).

This is getting a bit off-topic, but nowadays most aspects of general surgery can have fairly complex management, and this is why fellowships exist for every subspecialty of general surgery. Sure, one can sort of just cut the problematic tissue out, but to provide optimal patient care one should have a somewhat more nuanced approach. I think similar to vascular, in most fields, there are several management options for most clinical scenarios.

Specifically in oncology, over the last 20 years, there have been significant advances in multidisciplinary cancer care and an abundance of cancer-directed treatments, and intra-abdominal surgical oncology is anything but streamlined. The only abdominal cancer I can think of that has limited "correct" options is probably early colon cancer. Similarly, for breast cancer, anything other than early breast cancer in a low-risk patient can be fairly nuanced.

For the purpose of this topic, all of this can be learned during one's training, but a surgeon should at least have common sense, some capacity for learning, and, as @SLUser11 said, work hard.

 

[droliver]

After training general surgery, plastic surgery, PA, NP, RNFA, and dermatology residents for 15 years

1) you can train most people to operate competently as it's a repetitive skill to acquire, but there are some people whom are hopeless technically
2) there are some surgery residents whom will never, ever learn to "think right" about surgical patients and understand the how's and why's of how things should be done.
3) most resident whom fall into group 1 and/or 2 are usually identified within 6 months of starting residency by their peers

When we have someone on our service, I don't pimp at all about anything. I'll find a YouTube video for them to watch and then explain during the case why we do things and the important concepts to internalize (say like about a breast or abdominal wall case) and then proctor them through the mechanics of how to close a wound, use a cautery, choose what suture materials to use, etc..... That works so much better and is less intimidating then say. asking stupid things about who Theodore Kocher, Halstead, Galen,etc... was and do you know some esoteric classification system of condition X. Without fail, our residents tell me they learned more from us in 1 month of their intern year about how to do a mastectomy correctly, how to process the important information on a breast cancer path report, and what the considerations are on adjuvant therapy decisions then they learn the rest of the residency.

 

[odyssey2]

After training general surgery, plastic surgery, PA, NP, RNFA, and dermatology residents for 15 years

1) you can train most people to operate competently as it's a repetitive skill to acquire, but there are some people whom are hopeless technically
2) there are some surgery residents whom will never, ever learn to "think right" about surgical patients and understand the how's and why's of how things should be done.
3) most resident whom fall into group 1 and/or 2 are usually identified within 6 months of starting residency by their peers

When we have someone on our service, I don't pimp at all about anything. I'll find a YouTube video for them to watch and then explain during the case why we do things and the important concepts to internalize (say like about a breast or abdominal wall case) and then proctor them through the mechanics of how to close a wound, use a cautery, choose what suture materials to use, etc..... That works so much better and is less intimidating then say. asking stupid things about who Theodore Kocher, Halstead, Galen,etc... was and do you know some esoteric classification system of condition X. Without fail, our residents tell me they learned more from us in 1 month of their intern year about how to do a mastectomy correctly, how to process the important information on a breast cancer path report, and what the considerations are on adjuvant therapy decisions then they learn the rest of the residency.

I wish everyone involved in teaching medicine did what you do.