How technically competent do you expect a sub-I to be?

[ChordaEpiphany]

I'm about two weeks into my first sub-I on a fairly low volume service. I'm not getting a ton of OR time (2-3 days/week). I also had a different core clerkship than most of my classmates applying into surgery, which didn't have me as involved in the OR as some other students might have been. I'm wondering where the bar is on overall technical skills as I feel I might be a little behind.

To be specific, my tying is very solid. I throw very smooth one-handed knots. I can easily close a few ports quick enough to not annoy the anesthesiologist, and probably 2 of 3 of them will be good, but usually one has a small dimple or isn't quite superficial enough to completely bring the edges together without dermabond. I can do a subcuticular, and the end product looks decent, but I was somewhat inefficient with my suture use, and my senior was pretty critical of my overall movements and technique today. I'm definitely clunky at times. In the last week, I dropped the loop on my Aberdeen hitch once and had to fumble with it for at least 30 seconds to sort it all out, which my senior noticed, and I bent my needle doing a subcuticular.

My senior has been completely awesome and supportive, showing me lots of tips to improving my economy of movement and overall ergonomics. I'm definitely improving every time I go to the OR. However, I was recently pulled from clinic and moved to a high-volume service for a few days, and it's just dawned on me that this could be their way of saying I need more practice/volume/exposure. If this is the case, obviously I'm grateful their response is to get me that needed volume, but I'm also concerned I might be pretty far behind and making a bad impression. I practice at home when I have time (though I don't have much), but nothing really replicates human skin well enough to sort out these issues.

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[ArmyTiger]

No one cares how technically adept the medical student is, not really. The intern needs to be proficient at closing skin and tying knots, but that's by the end of the year. As long as you're getting better, any technical proficiency is good enough. Real operations come later.

 

[LucidSplash]

Honestly the job of a sub-I IMHO is to act like an intern to the best of their ability and I don’t expect interns to have perfect surgical technique - as the saying goes “It’s a 5-year program” for a reason. And I don’t expect sub-Is to be in the OR primarily. As with interns, for the sub-I being in the OR some is necessary and great, but the primary focus is to learn perioperative management, learn to recognize sick from not sick, begin to learn to recognize who needs surgery and who doesn’t, work on communication skills with other services, etc.

Almost everyone can be taught the technical aspects of surgery. Very few are born truly gifted technically. Many more people struggle with what happens outside the OR than inside it.

You are overthinking.

 

[ChordaEpiphany]

Honestly the job of a sub-I IMHO is to act like an intern to the best of their ability and I don’t expect interns to have perfect surgical technique - as the saying goes “It’s a 5-year program” for a reason. And I don’t expect sub-Is to be in the OR primarily. As with interns, for the sub-I being in the OR some is necessary and great, but the primary focus is to learn perioperative management, learn to recognize sick from not sick, begin to learn to recognize who needs surgery and who doesn’t, work on communication skills with other services, etc.

Almost everyone can be taught the technical aspects of surgery. Very few are born truly gifted technically. Many more people struggle with what happens outside the OR than inside it.

You are overthinking.

I thought about this during M&M today, and it absolutely rings true. The vast majority of errors are in diagnosis, management, and systems failures. I also got the chance to scrub into 4 cases today. While I absolutely did whiff a few things in the morning, I could see massive improvement in just a single day in things like driving the lap cam, running subcuticulars, placing trocars, etc... I'm a lot more confident now that this is just something that will come with time. I probably am not massively gifted technically, but I'm also probably not behind the curve.

 

[DOVinciRobot]

You sound just fine. Your skills sound what I would expect out of an intern that less than 6 months in, which is pretty good for a 4th year. I’ve seen some 4th years that can’t even close port sites, let alone run a subcuticular.

Like others have said, I would focus on beginning to learn the peri-operative management of stuff. That’s what really ends up separating people, the decision making.

 

[ChiDO]

It's important to show growth (in knowledge and skills) during your rotations.

 

[ChordaEpiphany]

Just updating this for anyone in the future experiencing something similar. Because my service has been so slow, I've been hunting around for extra cases that don't have a resident or medical student and scrubbing on everything possible (with the support of my senior). I've been in 15 cases since I posted this and asked to do as much as possible in each. Got to close a ton and learned a few more specific skills on each case. I was asked to do a fascial, dermal, and subcuticular closure on an open chest today. They gave me one half and a new PA the other half. After scrubbing in on so many cases and getting in my reps, it was so satisfying to realize that I was going about twice the speed of the PA and had a comparatively much nicer looking closure. Just a week ago I was lagging majorly behind this new PA.

And I absolutely agree on perioperative management. Unfortunately, I'm getting very little of that. We have so few patients on this service (on my busiest days, I'm "carrying" the whole list of... 3-4 patients). I'm hoping future rotations on busy services and in the SICU will help to round out some of those skills.

 

[LucidSplash]

Just updating this for anyone in the future experiencing something similar. Because my service has been so slow, I've been hunting around for extra cases that don't have a resident or medical student and scrubbing on everything possible (with the support of my senior). I've been in 15 cases since I posted this and asked to do as much as possible in each. Got to close a ton and learned a few more specific skills on each case. I was asked to do a fascial, dermal, and subcuticular closure on an open chest today. They gave me one half and a new PA the other half. After scrubbing in on so many cases and getting in my reps, it was so satisfying to realize that I was going about twice the speed of the PA and had a comparatively much nicer looking closure. Just a week ago I was lagging majorly behind this new PA.

And I absolutely agree on perioperative management. Unfortunately, I'm getting very little of that. We have so few patients on this service (on my busiest days, I'm "carrying" the whole list of... 3-4 patients). I'm hoping future rotations on busy services and in the SICU will help to round out some of those skills.

On a not so busy service you have extra time to read. There should be no “unfortunately” at your stage of learning because the quantity of what you don’t know is vast and there are too many avenues for learning. On a busy service, you’ll find you have far less time to read and get a deeper understanding of your patients’ issues. So enjoy this time. You’ll never have quite so much freedom to learn again until you’re an attending.

 

[ChordaEpiphany]

On a not so busy service you have extra time to read. There should be no “unfortunately” at your stage of learning because the quantity of what you don’t know is vast and there are too many avenues for learning. On a busy service, you’ll find you have far less time to read and get a deeper understanding of your patients’ issues. So enjoy this time. You’ll never have quite so much freedom to learn again until you’re an attending

Oh yeah, I'm reading a ton about the patients we do have on service and about this surgical specialty as a whole. I'm starting a "bank" of personalized notes on each procedure and condition I see. The goal is to have a rough outline of all the bread and butter from each specialty so every time I manage a patient and learn something new, I can add to that "bank" of notes.

When I say I can't learn as much about perioperative management, I mean it's hard to understand how the floor works. My chief told me the same. It's very hard to "study" the next step for a patient who maybe has an ileus and maybe doesn't with equivocal imaging and a bunch of confounding factors. There are so many questions that are attending dependent or just poorly taught in learning resources because it's assumed you'll learn it on the wards or it's simply better taught on the wards than in a book. Can we pull the chest tube if it put out 220 ccs in the last 24? Should the NG tube come out now or in the evening in this patient with resolving SBO? The patient looks great, are they ready for discharge now, or do we need to see them advance from liquid to soft diet? How does this patient's intellectual disability and abnormal presentation of discomfort affect our management of their appendicitis?

I thought it was really corny at first, but "patients are the best teachers" is true. You have to supplement patient care with extensive reading, but Sabiston's is only going to take me so far on its own. If there are cases to do, that seems like a better option than trying to read a textbook in the workroom while the interns from some other specialty gossip loudly at the next computer. One of the surgeons is on a leave right now. If I only did cases from this service, I'd be in the OR for 2 cases/week and barely seeing patients.

 

[LucidSplash]

Oh yeah, I'm reading a ton about the patients we do have on service and about this surgical specialty as a whole. I'm starting a "bank" of personalized notes on each procedure and condition I see. The goal is to have a rough outline of all the bread and butter from each specialty so every time I manage a patient and learn something new, I can add to that "bank" of notes.

When I say I can't learn as much about perioperative management, I mean it's hard to understand how the floor works. My chief told me the same. It's very hard to "study" the next step for a patient who maybe has an ileus and maybe doesn't with equivocal imaging and a bunch of confounding factors. There are so many questions that are attending dependent or just poorly taught in learning resources because it's assumed you'll learn it on the wards or it's simply better taught on the wards than in a book. Can we pull the chest tube if it put out 220 ccs in the last 24? Should the NG tube come out now or in the evening in this patient with resolving SBO? The patient looks great, are they ready for discharge now, or do we need to see them advance from liquid to soft diet? How does this patient's intellectual disability and abnormal presentation of discomfort affect our management of their appendicitis?

I thought it was really corny at first, but "patients are the best teachers" is true. You have to supplement patient care with extensive reading, but Sabiston's is only going to take me so far on its own. If there are cases to do, that seems like a better option than trying to read a textbook in the workroom while the interns from some other specialty gossip loudly at the next computer. One of the surgeons is on a leave right now. If I only did cases from this service, I'd be in the OR for 2 cases/week and barely seeing patients.

You’re experiencing the part of medicine that’s an art. One of my favorite attendings would say “Good judgement comes from experience, but experience comes from poor judgement.”

The attending that can fix pretty much any clusterf**k in the OR can do that because of all the ways they’ve caused a clusterf**k at some point. The attending or senior resident that has a “6th sense” about a patient going down the tubes is really just accessing the collective experience of all their prior patient encounters. Definitely some things are because a given attending likes to do things a certain way but that is also helpful. I often tell trainees that our job is to give you a toolbox. I may do things way X primarily and another surgeon way Y as a preferred method. But someday when you look across the table and you’re the most senior person in the room, the idea is that your toolbox contains both X and Y.

Assuming you’re rotating on gen surg, not sure if the kids are using Fiser’s ABSITE review book anymore. But if you’re taking notes would consider a pocket-size review book like that and making yourself additional notes in the margins. Likely to save you a lot of work and also most of your basic pimp question answers will be easily found there.

 

[EngineerPreMD]

You sound just fine. Your skills sound what I would expect out of an intern that less than 6 months in, which is pretty good for a 4th year. I’ve seen some 4th years that can’t even close port sites, let alone run a subcuticular.

Like others have said, I would focus on beginning to learn the peri-operative management of stuff. That’s what really ends up separating people, the decision making.

Am I crazy, or are port sites way harder than running a subcuticular? Port sites are so variable. Sometimes I can nail 3-4 in a row perfectly with no issues. Other times I leave gaps or need to redo them because I button-holed or something. You get people with super floppy skin, especially after insufflation, and others with weird, thick dermis. I just had a day where the attending trusted me to do deep dermals and then running subcuticular on a patient's neck and it went perfectly. The next case I had to close two port sites, but the guy had super thick dermis and extremely floppy skin (palliative surgery for metastatic cancer, recent 100 lb+ weight loss). I ended up getting bailed out by the resident on the second.

 

[DOVinciRobot]

Am I crazy, or are port sites way harder than running a subcuticular? Port sites are so variable. Sometimes I can nail 3-4 in a row perfectly with no issues. Other times I leave gaps or need to redo them because I button-holed or something. You get people with super floppy skin, especially after insufflation, and others with weird, thick dermis. I just had a day where the attending trusted me to do deep dermals and then running subcuticular on a patient's neck and it went perfectly. The next case I had to close two port sites, but the guy had super thick dermis and extremely floppy skin (palliative surgery for metastatic cancer, recent 100 lb+ weight loss). I ended up getting bailed out by the resident on the second.

Dermabond fixes most port site ills lol

But yes, I remember as a student thinking port sites were harder too

 

[EngineerPreMD]

Dermabond fixes most port site ills lol

But yes, I remember as a student thinking port sites were harder too

The issue is that even if you can approximate the skin with some tension and then dermabond over, the resident still judges you and tells you to do it over (or worse just cuts yours out and does it themselves). Some patients have this super thick skin or absolutely no elasticity whatsoever. Some have port sites that are charred to hell from the resident bovie'ing it to death. Some of the port sites are just out-of-whack to start. I do great when it's a healthy patient (e.g., 50s lap chole), but the 2x irradiated patient with recent 100 lb weight loss? That's hard.

I can do literally all the other classic sub-I tasks well. One attending let me close the neck on a thyroid patient and I had absolutely no issues doing deep dermals and then knotless subcuticular. If I can pat myself on the back a little, the end result was extremely clean. I can close fascia. I can suture in a drain. However, my direct evaluator primarily sees me on laparoscopic cases, and they think I can barely cut.

Being a sub-I absolutely stinks. On my team I'm basically an appendix. On my best days I'm a gallbladder.

 

[LucidSplash]

The issue is that even if you can approximate the skin with some tension and then dermabond over, the resident still judges you and tells you to do it over (or worse just cuts yours out and does it themselves). Some patients have this super thick skin or absolutely no elasticity whatsoever. Some have port sites that are charred to hell from the resident bovie'ing it to death. Some of the port sites are just out-of-whack to start. I do great when it's a healthy patient (e.g., 50s lap chole), but the 2x irradiated patient with recent 100 lb weight loss? That's hard.

I can do literally all the other classic sub-I tasks well. One attending let me close the neck on a thyroid patient and I had absolutely no issues doing deep dermals and then knotless subcuticular. If I can pat myself on the back a little, the end result was extremely clean. I can close fascia. I can suture in a drain. However, my direct evaluator primarily sees me on laparoscopic cases, and they think I can barely cut. My main attending mumbles in the OR. He's a notorious mumbler (his close staff jokes they learned to speak his language). I can't hear a single word the dude says, and he never uses names or gives any clue who he's talking to so I have no idea if his directions are even for me. So when he says, "cut this" it just sounds like, "buh tiss" and I have no idea if I'm supposed to cut or if he's telling the resident to do something. Then, because I suck at the ports and sometimes reach out with scissors when the attending is actually asking for a snap, they don't let me do anything bigger.

Being a sub-I absolutely stinks. On my team I'm basically an appendix. On my best days I'm a gallbladder.

Welcome to surgery.

 

[chord]

I care more that my sub-Is have a good attitude, are team players, have good situational awareness, and don't complain/aren't off-puttingly weird. Technical skills are learnable and teachable.