How to prepare for surgery prelim internship

[drdel]

Hi everyone,

I'm sure this topic has been discussed before (I've been reading a few posts but they were a bit outdated), but I wondering what kind of advice anyone would give to someone preparing for a prelim surg year?

I didn't get into my specialty of choice in the Match and scrambled into a surg prelim position just to get the clinical experience (and paycheck). My expectations are extremely low, and I know it will be a miserable frickin' year doing the scuttiest of scutmonkey work, on very little sleep, getting yelled at by everyone, in addition to the anxiety of not knowing where I'll be the following year in terms of career. This much seems to be universally accepted as the norm for a prelim surg position, and I don't even know enough about the program yet to know whether or not it is malignant. Still, as everyone says, it's only one (painful) year out of my life to deal with, and I know it's an opportunity I can't dismiss lightly.

As a little background, I'm a US IMG who took a little time off after graduation to do some research. Turned out to be a great decision, as during this time I met a great guy and we're going to be married this summer (just 2 weeks prior to the start of internship, I just found out; guess it'll be a short honeymoon!). I'm very glad for that, as well as my family being located in the same borough (NYC), so I at least have some good personal support. I also have a past history of clinical depression that was treated and it's been years since I've had to deal with it, but I'm emotionally prepared to jump and get help if, after getting through the first couple months of hardcore adjustment period, I think I need it (I think getting prophylactic pharmacological help might be a little premature, but dunno).

I might be lucky in a sense; I'm a very good team player, I'm very aware of my place in heirarchies, and I'm very easy to get along with. I'm also a very hard and focused worker, and while not exactly a fan of chronic sleep dep, lord knows I've had experience with it before, so should be able to handle it again. And even though it wasn't my first choice, I actually really, really enjoyed surgery in med school and contemplated it as a career for a while but ultimately decided against it due to the lifestyle (not that I have any false hope of spending real quality time in the OR during internship; I'm telling you, my expectations really are rock bottom).

I'm generally a bit nervous because I've been away from clinical work for a while due to the research (bench, not clinical)... Gonna spend the weeks leading up to the start (minus wedding time) refreshing my knowledge, and I've already downloaded ABSITE prep material to start looking at.

Just wondering if anyone had any advice? The main advice I got from peers is to be kind and respectful to everyone, especially nurses, and try to be knowledgeable but generally keep your head down. I'm also mentally preparing to generally 'be wrong' about everything (that, plus the sleep dep, might be good practice for future motherhood! lol). Any other wisdom you'd like to share...?

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[Winged Scapula]

Good Lord, you're setting yourself up for a miserable year.

"Everyone yelling at <you>?" While that may be true in some places, I hardly think its the 10th level of Hell that you are expecting. Sleep deprivation? Not with the new rules; interns are very limited in number of hours in the hospital and on-shift.

To be truthful, a Prelim Surgical year isn't a lot of fun especially if you're trying to get a Categorical Surgery position. But for someone like you, the expectations (on both sides) will be low. You aren't gunning for a surgical position for next year, so you don't have to put on your happy face and dance all year long as an audition.

The advice is simple:

- be on time; heck, be early
- write everything down and have a system so you won't forget your chores
- don't call in sick...ever
- don't leave early...ever
- be proactive; when you order a test, know when its going to be done and what the results are. Don't wait for rounds to find out that the "stat" CT scan was never done.
- practice a quick, well rounded patient presentation for rounds
- if you have to take the ABSITE (not all Prelims do), then read a little about surgery every night; even if its just 10 minutes
- yes, be nice and respectful but don't be taken of advantage of
- know how to answer a page (the correct answer is not, "hello?"), call in a consult
- always "load the boat"; as a intern in this day and age, you won't be taking overnight call but if there's a problem patient let your seniors know
- everyone is "Sir" and "Ma'am" or "Doctor X" until you are told otherwise (eg, surgery is more conservative than other fields where attendings are often called by their first names)
- know where the bathrooms are, cafeteria hours, where to park, how to get scrubs and get to the OR, how to page someone, log on to the EMR, how long it takes you to get to the hospital, etc before your first day
- don't sign out **** that you should have done yourself
- make sure that your wedding doesn't conflict with orientation


The rest of the advice in older threads is still good.

 

[mimelim]

Good Lord, you're setting yourself up for a miserable year.

"Everyone yelling at <you>?" While that may be true in some places, I hardly think its the 10th level of Hell that you are expecting. Sleep deprivation? Not with the new rules; interns are very limited in number of hours in the hospital and on-shift.

To be truthful, a Prelim Surgical year isn't a lot of fun especially if you're trying to get a Categorical Surgery position. But for someone like you, the expectations (on both sides) will be low. You aren't gunning for a surgical position for next year, so you don't have to put on your happy face and dance all year long as an audition.

The advice is simple:

- be on time; heck, be early
- write everything down and have a system so you won't forget your chores
- don't call in sick...ever
- don't leave early...ever
- be proactive; when you order a test, know when its going to be done and what the results are. Don't wait for rounds to find out that the "stat" CT scan was never done.
- practice a quick, well rounded patient presentation for rounds
- if you have to take the ABSITE (not all Prelims do), then read a little about surgery every night; even if its just 10 minutes
- yes, be nice and respectful but don't be taken of advantage of
- know how to answer a page (the correct answer is not, "hello?"), call in a consult
- always "load the boat"; as a intern in this day and age, you won't be taking overnight call but if there's a problem patient let your seniors know
- everyone is "Sir" and "Ma'am" or "Doctor X" until you are told otherwise (eg, surgery is more conservative than other fields where attendings are often called by their first names)
- know where the bathrooms are, cafeteria hours, where to park, how to get scrubs and get to the OR, how to page someone, log on to the EMR, how long it takes you to get to the hospital, etc before your first day
- don't sign out **** that you should have done yourself
- make sure that your wedding doesn't conflict with orientation


The rest of the advice in older threads is still good.

This is why the quote button is here, so I don't have to write out a response.

 

[Medicus2013]

I've certainly got nothing to add to the infinite wisdom of our moderator, but I just wanted to wish you good luck in your upcoming year. A couple of my friends are getting ready to embark on the same journey and I can only imagine that it must be stressful.... Good luck!

 

[45408]

It won't be that bad.

It will be tough with regard to trying to get another residency position afterward, but the actual year won't be that bad.

 

[ShaggyDog]

So realistically, how difficult will it be to get a categorical gen surg position as a surgery prelim? I went unmatched this year for a competitive surgical subspecialty and now will be doing a prelim year.

I'm still trying to decide between reapplying (probably not), looking for categorical spots in gen surg vs subspecialty or anesthesia.

 

[45408]

So realistically, how difficult will it be to get a categorical gen surg position as a surgery prelim?

Pretty difficult. Spots open up periodically, but there aren't nearly enough for everyone.

 

[survivordo]

Winged Scapula covered it but I will add to keep a positive attitude. Work only sucks if you let it get to you!

Survivor DO

 

[mimelim]

So realistically, how difficult will it be to get a categorical gen surg position as a surgery prelim? I went unmatched this year for a competitive surgical subspecialty and now will be doing a prelim year.

I'm still trying to decide between reapplying (probably not), looking for categorical spots in gen surg vs subspecialty or anesthesia. I don't really want to do anesthesia, but if that's my only option...

The GS program at the hospital I'm at kept 1 out of 2 pre-lims as a 2nd year pre-lim, which is pretty typical, our 2nd year prelims almost always get a 3rd year categorical spot either with us or elsewhere. Our neighboring program takes 1 out of 5 every year very consistently.

 

[blue2000]

Also, even though you think you'll only be there for a year, make the effort to get to know and become friendly with your intern class. Many of them are just as anxious and worried as you are, and you need each other to get used to this new culture. Have each other's backs, go out for drinks, decompress and tell bad jokes. It'll make the pain more bearable.

 

[poorracerkid]

So realistically, how difficult will it be to get a categorical gen surg position as a surgery prelim? I went unmatched this year for a competitive surgical subspecialty and now will be doing a prelim year.

I'm still trying to decide between reapplying (probably not), looking for categorical spots in gen surg vs subspecialty or anesthesia. I don't really want to do anesthesia, but if that's my only option...

Don't do anesthesia if it's not what you really want to do. You will be setting yourself up for unhappiness for your whole career. My advice would be to reapply if your heart is truly in surgery and look at all your other options if it's not. Sorry to hear you didn't match.

 

[drdel]

Thanks, everyone (especially WingedScapula)! Sorry I didn't reply sooner; I haven't posted in SDN in literally years and I didn't know that I didn't have my account set up to email me when I get responses, so I thought no one replied!

I just finished watching Bob's Burger's, where an intern treating his first patient without an attending around to help is checking videos on his phone on how to suture Bob and mangles it horribly, lol. It unfortunately struck too close to home and I started getting anxious and decided to dig more on SDN to find out what to expect as a prelim, and decided to check my post. So glad I did!

I guess it's just that surgery prelim has the WORST reputation in terms of post-graduate training, and you hear such horror stories about it... It kinds of feels like a self-protective measure to expect something close to the 10th circle of hell... and then be pleasantly surprised to find it's only the 5th

I would be nervous about it general, but feel doubly, or even triply, so because it's been a while since graduation and clinical experience. And frankly, as a European med school grad, my US elective experience was limited (unlike the Caribbean schools, it seems), and only one surgical elective. So I never quite got comfortable with the system of rounding, notes, and signout that I guess most MS3s pick up pretty quickly.

I don't even know the 'correct' answers are in some of the scenarios mentioned...
-- know how to answer a page (the correct answer is not, "hello?") ... What is it, then? Just name? or also identify myself as surgical intern?
-- "load the boat" ... Sorry, I'm unfamiliar with this term; can you please explain?
-- know where the bathrooms are, cafeteria hours, where to park, how to get scrubs and get to the OR, how to page someone, log on to the EMR, how long it takes you to get to the hospital, etc before your first day... While I didn't do an elective at this particular hospital, luckily I am kind of familiar with the first half of these things. We have about a week of orientation days (starting just two weeks after the wedding ceremony, so enough time for a little honeymoon, thankfully!!), so I certainly hope I'll learn the OR-specific and technical stuff then.
-- don't sign out **** that you should have done yourself ...Meaning what?


Thanks for the heads-up on surgery being a more conservative specialty, too. I'm very laid back and informal and pretty much always prefer people to address me by my first name. It's a good reminder that others aren't necessarily the same.

I unfortunately don't know anything about this program and whether or not it is malignant. I guess it's just fear of the unknown. I hope to keep up my generally positive attitude, and especially hope to befriend a couple people (residents, nurses, anyone) who can help me laugh and keep things in perspective in the hospital and make it seem more pleasant (as blue2000 said).

Guess I'm also a little worried about the fledgling marriage, too. I figure the first month or so I'll be crashing nearby with family til I get used to the hours and such. Then I hope to transition to commuting more (already looking into getting a beater for this purpose) so can physically see new hubby more often... tho I feel pretty sure he's just gonna watch me sleep most of the time! I know even just having him in my life will be helpful to me emotionally, but I know this circumstance is gonna be stressful to him/us. But shall see.

Too many things to potentially be worried about, and not enough information to allay the fears. But I suppose it's all guesswork, trying to anticipate what an internship will be like, especially in terms of dynamics. I just have to remind myself to chill out about it and take whatever may come, as it comes. I'm also torn between spending these last few weeks frantically studying and trying to prepare to remind myself of stuff, or relaxing like HELL while I still can




As an aside, anyone ever check out rookiedoctor.com? I came across it last week when I was freaking out about internship, and though the site generally has me wary, he has a little 12 minute video clip on there recounting his internship and how he was on the edge of burnout/dropout, especially because of his need/desire to have everything perfect and keep on top of everything, etc.(which sounds a lot like me, as a perfectionist and little bit of a control freak). Apparently an attending intervened and told him a simple fact: the role of the intern is to gather information... from the patient, from family, other doctors/nurses/whatever. To gather and relay information in a timely and efficient manner. That's it. That's the key role in terms of other residents, the attendings, etc. I thought that was an interesting perspective, especially if true. I don't know that it can be summed up so simply. Any thoughts...?

 

[Winged Scapula]

...

I don't even know the 'correct' answers are in some of the scenarios mentioned...
-- know how to answer a page (the correct answer is not, "hello?") ... What is it, then? Just name? or also identify myself as surgical intern?

I mention that because I recall one July 1st where the intern on Pediatric Surgery had to be told that it was *his* pager that was going off and when he answered the page he just said, "hello?". The attending and I just laughed. The correct way is (some form of):

"Hello, this is Drdel answering a page for the <insert name> service.

-- "load the boat" ... Sorry, I'm unfamiliar with this term; can you please explain?

This means that when a patient is crashing (not doing well), it helps to "load the boat" with the most experienced people. In short, tell your senior residents/Chief when things are going wrong or you are having problems. Heck, in the beginning you should let them know when anything is going on.

-- don't sign out **** that you should have done yourself ...Meaning what?

That depends. But in general, it is ok to sign out labs to check at 10 pm or post-op checks, but it is not ok to sign out a drain/tube that should have been removed several hours ago, talking to family, etc. There are a thousand examples but IMHO anything that you were assigned to do/check up on during your day should be done by you

Apparently an attending intervened and told him a simple fact: the role of the intern is to gather information... from the patient, from family, other doctors/nurses/whatever. To gather and relay information in a timely and efficient manner. That's it. That's the key role in terms of other residents, the attendings, etc. I thought that was an interesting perspective, especially if true. I don't know that it can be summed up so simply. Any thoughts...?

While an oversimplification, it is the job of the intern to collect data and to relay that information in a timely and efficient manner. But is is also the intern's job to learn how and why that information is important.

Please do not follow all the information in this link to the letter (since much of it is program specific) but I thought it might give you some guidance. I'm sure many programs have other ones available.

 

[drdel]

Thank you, WingedScapula -- You are now officially and sincerely my favorite person I've never met

 

[45408]

I don't even know the 'correct' answers are in some of the scenarios mentioned...
-- know how to answer a page (the correct answer is not, "hello?") ... What is it, then? Just name? or also identify myself as surgical intern?
-- "load the boat" ... Sorry, I'm unfamiliar with this term; can you please explain?
-- know where the bathrooms are, cafeteria hours, where to park, how to get scrubs and get to the OR, how to page someone, log on to the EMR, how long it takes you to get to the hospital, etc before your first day... While I didn't do an elective at this particular hospital, luckily I am kind of familiar with the first half of these things. We have about a week of orientation days (starting just two weeks after the wedding ceremony, so enough time for a little honeymoon, thankfully!!), so I certainly hope I'll learn the OR-specific and technical stuff then.
-- don't sign out **** that you should have done yourself ...Meaning what?

I made a thread about this stuff when I started my intern year, and there were great posts then - http://forums.studentdoctor.net/showthread.php?p=12649117

As for your question of what signing things out that you should have done yourself - take a look at page 2 of the thread I posted, and you'll see my thoughts as well as other people's thoughts of what constitutes signing things out appropriately.

 

[drdel]

Thanks, TheProwler! That whole thread is full of immensely useful information... I think I'm going to have to start constructing my own internship guidebook from people's advice on SDN and then see how it coincides with whatever little tidbits they try to teach during actual orientation


Relatedly, I just found out that my position is officially an unaccredited, undesignated prelim.

Upside (I guess) is that I found out definitively that I don't have to take the ABSITE (which I was kind of hoping to do, as an opportunity to make a good impression in general, but maybe this is for the best). Downside is that I also don't have an education stipend, which is a little disappointing. At this point, I'm not even sure if I'm supposed to go to any didactics (I'll bet they're certainly not 'protected' for me).

While none of this is truly surprising, it still is a bit disappointing. I already feel like the red-headed stepchild. Or second-class citizen... I already had that feeling as an IMG, but this feels more acute. Especially since this program apparently has accredited prelims as well, so I'll be even a second-class citizen amongst the prelims. Kinda sucks that I'm not really 'supposed' to be learning something, just doing my job. Scutmonkey extraordinaire! I guess the structured educational gestation period is over...

...But that's okay. It needed to happen sometime! I guess it's best just to accept my role and embrace it -- SOMEone has gotta be the low man on the totem pole! Now I'm just fervently hoping for some nice/fun coworkers, as I know they are the ones who can make the difference of having a tough situation be either bearable (or dare I hope, pleasant?) or malignant.

(this became a little bit more of a journal entry than topic discussion, but I get the impression SDN is good for expunging stuff from your mind amongst people in similar situations, so I took the opportunity)

 

[Winged Scapula]

Relatedly, I just found out that my position is officially an unaccredited, undesignated prelim.

Are you sure about the bolded part and are you using the term correctly?

I would not recommend training in an unaccredited program (never heard of an unaccredited position). Besides all the possible issues with quality of training, the American Board of Surgery is not going to give you credit for time served in an unaccredited internship, thus requiring you to repeat the intern year elsewhere in an accredited program. In addition, the ABS restricts the number of programs you train at in order to be board eligible, so spending a year at an unaccredited program is taking one of those years but without giving you credit for it (ie, you won't be eligible for an accredited PGY-2 position).

 

[drdel]

Unfortunately, I think I am using it correctly. This is the reply the program coordinator sent to me after I inquired about the educational stipend:

"The preliminary resident and categorical residents, accredited by the ACGME, do receive a stipend. However, you are a non-accredited resident, there is no stipend offered."

And on the front cover the contract they sent, there was a list of classifications that would apply and they checked off "PGY-1" and "Adjunct Teaching/Non-Accredited"... NOT "Preliminary" and certainly not "Categorical."

Unfortunately, it's a little too late now, as I've already signed and returned the contract. My thinking was that it was better than nothing (though perhaps not by much). That it is a year of clinical training in the USA, fairly close to home, and a paid position. (As an IMG I had less than a year of clinical electives, taken in NYC, during my fourth year). Plus it took a little fighting just to get this.

I guess in a way it doesn't matter too much if it's unaccredited... Initially I thought it would be good to have a PGY-1 under my belt as a basis for other residencies, like Preventive Medicine, which I have been seriously considering for a while now, but last week in my research I found out that as an IMG, I wouldn't be able to get into Preventive Medicine anyway, since PrevMed programs requires either state licensure or to be eligible for state licensure, and NY state (my home) requires IMGs to participate in 3 years of a hospital-based residency in order to get a license... so even if this internship counted for anything, I would STILL have to get another residency. So I would've had to try for FamMed or something else for next year anyway.

So basically this fall I'll be applying for all sorts of things in the Match and hoping for the best. I just didn't want to spin my wheels for another year earning a pittance, like I've done this last year after I didn't successfully Match/Scramble last season... especially since, as I learned, there is no guarantee of finding a position.

I decided to study medicine abroad because it sounded fun, and a unique life experience. I don't regret the experience itself, but it certainly has made my career path extremely difficult in ways I didn't expect, and that I regret. I also seem to have an amazing knack for finding the most difficult way to do things. Still, I wouldn't mind some input into whether or not this unaccredited prelim surgery spot may be something I will regret later.

Besides, I may be showing my complete lack of understanding here, but I thought that if it were to be unaccredited, then the issue of having funding for residency training (up to 5 years by CMS, is my understanding) should be a little moot? Or maybe I'm just somehow thinking that CMS wouldn't fund unaccredited positions, but maybe they would. This would still be solved by trying to match into a residency that is four years or less (i.e., not surgery), no? If that's the case, then I suppose it wouldn't be a problem, since my dream is pathology (though pathology programs don't seem to like me as much as I like them), and I would take Family Med or something else as a back-up.

I guess bottom line is, even though I expect this year to be difficult, I figured the experience could only help me -- help me clinically in terms of refreshing my knowledge, and help me in terms of adding significant clinical experience to my CV. If you think that it would be a joke and no one would take it seriously -- like the 'observership' I did two years ago -- I'd like to hear that

It just occurred to me -- is this pretty much what they call an externship? Paid clinical work in the US that's not a medical residency? Cripes, I'm getting getting confused... Maybe I'd better ask about this in the General Residency Issues forum...