procedures

[tasmanian]

what are you guys expecting from your operative experience after 1 and 2 years of training (lets say general level of complexity and difficulties) - what should you be confortable to do by yourself
Here is my vision:
1 - hernias, appies (includining not only student ones), varicous veins, amputations, perianal zone etc. - something like this
2 - chole, perforative ulcers, gasral resection (ulcers, tumors?), anastomoses, embolectomies?, spleenectomies etc... somethinglike that
I do understand it is a little skewed toward abdomen ... but this will probably be the first thing we encounter.

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[dr.evil]

Feel comfortable is the primary statement there.

After 2 years of training I am completely comfortable with the following cases by myself:
Port-A-Cath and all lines
EGD/Colonoscopy
Hernias (inguinal, ventral, incisional)
Choles
Appy's (laparoscopic and open)
Amputations
Right colectomy, Sigmoid colectomy, LAR
Debridements and Skin Grafts
Hemorroidectomy (PPH and Conventional)
Sphincterotomy
I'm close on carotids but I'll get a few more under my belt before I say
Trach/G-tube
Anything Breast
All arteriorvenous fistulas and dialysis access

These are all things I've had a lot of exposure to and feel very comfortable doing.

Things I've got to learn more about:
Anything esophagus, stomach (except for Graham patch of an ulcer), liver, pancreas, APR, Vascular (fem-pop, AAA, carotid, etc), Thyroid/Parathyroid, Kidney, Spleen, Adrenal, Lap Nissen's, Lap Gastric Bypass, etc.

Our chiefs tend to do most of these cases while I did the ones written above. I'm close with Thyroids, Parathyroids, Spleens and Carotids though.

So I'm biased but you should probably be comfortable with most of the cases above after 2-3 years (prior to chiefdom)

 

[fourthyear]

This will vary hugely depending on program. Community programs and smaller academic programs probably tend to give more early operative experience and the big name academic centers will tend to use you as more of a scutmonkey early on and don't let you operate much in the first 2 years. Also, many programs use year 2 as a heavy ICU year, so you may not get too much that year.

For my program, I agree with the types of cases you listed in 1 as being those I'm getting pretty comfortable with with my years 1 and 2 experience(currently in 2nd year). I'd add to your list in this category: skin lesion biopsies, soft tissue biopsies, breast biopsies, wound debridement, abscesses, chest tubes, central lines/port-a-caths/temporary dialysis accsess, trach, G-tubes.

Your list in category 2 seem more like cases for 3rd yr and up residents at my program. 2nd years may get lap choles, but the other cases you listed are a bit more advanced.

 

[Celiac Plexus]

After one year, I'm totally comfortable with:

-filling out discharge instructions
-dictating discharge summaries
-signing verbal orders
-writing prescriptions
-dealing with various social service agencies to arrange anything from free rides to home wound care
-transporting patients

 

[tasmanian]

This is a painful statement Celiac ?!
Is it what you expected from your training or what you have been confronted with ? Did you know/ heard about this issue befor entering the program?
Maybe you are getting heavily prepared to shoot in terms of theoretical knowledge ?
please clarify

 

[buggs]

After 2 months of internship I feel comfortable that I can show up on time and not much us.

 

[powermd]

After one year, I'm totally comfortable with:

-filling out discharge instructions
-dictating discharge summaries
-signing verbal orders
-writing prescriptions
-dealing with various social service agencies to arrange anything from free rides to home wound care
-transporting patients

Dude, I'm 6 weeks into my MEDICINE internship, and I can say I EXCEL at all of the above. Imagine where I'll be after a whole year of this intense medical training. Does this give me the right to brag I'm as skilled as a second-year surgery resident? Oh, I placed my first central line the other day. Go me!

 

[Celiac Plexus]

jesus... can anyone take a joke? eat some xanax, and swallow some bourbon..... yipes

 

[Foxxy Cleopatra]

After one year, I'm totally comfortable with:

-filling out discharge instructions
-dictating discharge summaries
-signing verbal orders
-writing prescriptions
-dealing with various social service agencies to arrange anything from free rides to home wound care
-transporting patients

Ha- classic! I'd have to add:

-updating the team patient list
-knowing where to find free food
-wiping sh#t out of sacral decub wounds and stuffing gauze back in

 

[droliver]

Feel comfortable is the primary statement there.

After 2 years of training I am completely comfortable with the following cases by myself:
Hernias (inguinal, ventral, incisional)
Choles
Right colectomy, Sigmoid colectomy, LAR
I'm close on carotids but I'll get a few more under my belt
Anything Breast
All arteriorvenous fistulas and dialysis access
I'm close with Thyroids, Parathyroids, Spleens and Carotids though.

So I'm biased but you should probably be comfortable with most of the cases above after 2-3 years (prior to chiefdom)

Sorry to interject on this & I'm not condescending, but it strain credibility to think that you are anywhere near competent with a lot of those procedures you're throwing out there after 2 years of residency. You may have assisted & been steered thru some of them, but that's not the same as having much proficiency. If you think you are, I'd argue that you haven't seen enough variants & complications yet. You need hundreds of each of those kinds of cases to get a feel for them. Most people even in the first few years of their practice would be a little careful about making claims with some of thoses case catagories or you wouldn't be seeing so many referrals for complications from them from community surgeons

 

[powermd]

I did get the joke.. apparently you didn't get mine. Funny post, seriously.

 

[Celiac Plexus]

i was actually referring to tasmanian's post...

i forgot to mention that I am pretty good at identifying maggots in diabetic feet... which is actually not a bad thing... the maggots i mean...

 

[dr.evil]

Sorry to interject on this & I'm not condescending, but it strain credibility to think that you are anywhere near competent with a lot of those procedures you're throwing out there after 2 years of residency. You may have assisted & been steered thru some of them, but that's not the same as having much proficiency. If you think you are, I'd argue that you haven't seen enough variants & complications yet. You need hundreds of each of those kinds of cases to get a feel for them. Most people even in the first few years of their practice would be a little careful about making claims with some of thoses case catagories or you wouldn't be seeing so many referrals for complications from them from community surgeons

I'm not sure what cases you're referring to exactly. At some point in your training, you feel comfortable going out and doing these cases without attendings backing you up. There's no perfect number of certain cases to say you're comfortable. There's also no way you've seen every complication or variant or even done "hundreds" of these case prior to graduating. So, feeling comfortable to me means I could do it alone, without an attending and feel confident I'm doing the right thing. Would I be nervous? Of course. Most people are nervous their first year in practice.

I whole heartedly stick with my statement. I can honestly say that I could go out and do outpatient general surgery stuff without backup. Will I have complications? Of course. But I DO NOT need someone standing over my should to show me how to do an inguinal hernia or a port-a-cath. I may be pushing the evelope with an LAR but I've done ~30 Right and Left Colectomies and could honestly do these without staff.

I'm truly not trying to be a braggard or someone who thinks their great at all things but I truly feel very confident doing the list presented. In my first 2 years of residency, I did over 100 dialysis access procedures which is plenty to make you comfortable (and not all of those went smoothly by the way).

Like I said, I definitely need more Endocrine, Carotids, and Spleens but if you can do it at an outpatient surgery center, I'll do it.

BTW, I'm also quite proficient in H&Ps, Consults, and Discharge Summaries/

So, doubt me if you will, that's fine. But many programs across the country don't wait until their 4th year to begin to actually see the O.R.

 

[FliteSurgn]

I've done ~30 Right and Left Colectomies and could honestly do these without staff.

Were you standing on the right or left side of the patient for those right colons? If you're on the patient's right, you're just running the Bovie while the staff act like you're doing the case. Most abdominal cases are easier with the surgeon on the contralateral side of the pathology.

I actually argued about this with a staff once...he was professing to a junior resident in the OR that to do a right colon or open chole, the operating surgeon HAS to stand on the right side...but then I asked him where he would stand if he were doing the case with a nurse and not a resident...his answer wasn't the right side...after some more discussion, his light bulb finally started to glow.

I don't mean to pull your chain either, but I came from a program that had a lot of early operative experience and I find it had to believe that someone could be comfortable with all of those cases after just 2 years too. It makes you wonder what the other 3 years of residency will hold, if almost every case that a typical general surgeon performs can be mastered in 2 years of training or less...even with the 80 hour workweek!

 

[droliver]

So, doubt me if you will, that's fine. But many programs across the country don't wait until their 4th year to begin to actually see the O.R.

I realize there are differences b/w programs in case volume (My numbers were in the 99%+ when I turned my ACGME case log in for boards two years ago), but I just will stand my ground on this one. There is no way you can acquire the skills, judgement, or experience to be proficient in a number of those cases after 2 junior years of residency period

 

[dr.evil]

So frustrating but anyway... I still don't know what cases you are referring to exactly. Some of the LAR's I have done have been myself and a 4th year with staff poking their head in to make sure we're doing OK. So for that, my 4th year had to be very comfortable doing the case to make sure I didn't screw up.

I've always found it interesting how people are critical that you can't learn to do basic general surgery in 2 years. You're kidding right? If you're in the O.R. every single day and are doing your 50th inguinal hernia do you think you need to do 50 more to at least be comfortable? I mean, Cardiothoracic Surgery is a 2 year fellowship. Do you not think you can learn those procedures in 2 years and be comfortable? I sure hope so because they've been doing it since the beginning of the specialty.

I'm not criticizing whether you're in the 99% in case numbers. Most programs like Louisville are a little top heavy and you operate like mad your 4th and 5th years. I've just operated a lot in my first 2 years. When you spend 2 months straight doing nothing but breast cases, you get pretty "comfortable". When you spend 6 months your first year doing mostly dialysis access, you get pretty "comfortable". When you spend 8 months doing nothing but hernias, port-a-caths, lap choles and colorectal, you get pretty "comfortable".

It's a tough subject to argue and really not worth our time.
BTW, after the 1st three right colons (which I stood on the right side and ran bovie) I've stood on the left ever since. I've tried to stand on the right on a left colectomy but really didn't prefer it as I'm right handed and had a tough time in the pelvis from the right. I therefore stand on the left and do the case. To each his own.

Anyway, what cases do you guys really think you should be comfortable with by the end of your 2nd year? Just interested.

 

[Tenesma]

drevil... what i think droliver is saying is that you may be comfortable doing a straightforward procedure, but your statement that you are "completely comfortable by yourself" implies that you would be able to manage side-issues... Ie: how would you repair an inadvertent tear of the CBD during your chole, what would you do if the trachea is calcified and you can't cut in between the rings with your blade, doing an EGD on somebody s/p colonic interposition, doing a retroperitoneal appy laparoscopically, what would you do if you placed your trocar into the bowel or even worse into the Iliac vein.... and your statement that you are close to being comfortable with carotids!!! how many eversion CEAs vs conventional CEAs have you done? how often have you had to convert an eversion CEA to a shunt and then repair over that?

to compare your 2 years of gen surg experience to 2 years of fellowship in CT surgery is a poor comparison.... you are still learning the basics of patient management and you have obviously gotten a lot of operative exposure, don't confuse that with expertise. I have worked with many PGY2s in the OR and it is very clear what they are comfortable with... I would say maybe by the end of PGY3 and beginning PGY4 could you make the statement that you are comfortable, but humble enough to know when to call for help...

 

[FliteSurgn]

to compare your 2 years of gen surg experience to 2 years of fellowship in CT surgery is a poor comparison.....

Exactly. CT fellowship is taking a proficient, fully trained general SURGEON and teaching him (or her) a few new operations...general surgery is taking a fully trained MEDICAL STUDENT and teaching them a sh*tload about operating, patient management, social services, etc.

I really don't mean to badger you about this, dr evil. I think that most of the cases you listed ARE appropriate for PGY 2-3 residents to feel okay performing. But, to be "completely comfortable" with most of colorectal surgery by your second year is a stretch. At least you realize you may have a little to still learn about thyroids, parathyroids, and carotids. I did 5 parathyroids my 2nd year, but I don't think that I would've said that I was completely comfortable with them for a few more years. BTW, the average graduating chief resident in this country has fewer than 5 of those during their entire training.

The pelvic dissection is easier for a righty from the left, but the mobilization of the splenic flexure sure isn't! Like I posted above, I had a few attendings that were very reluctant to give up their "assisting" side of the table...lol. This brings up something...I was at a SAGES laparoscopic course a year or two ago and was helping teach someone how to do a lap nissen on a dog. One of the lecturing surgeons, a very accomplished laparoscopist and head of a minimally invasive fellowship, came over and was watching. He started giving pointers that were difficult to perform ergonomically (and a mirror image of what I was telling him to do). It became obvious to me that he performed his nissens from the left side of the table based on his directions to the operating surgeon. Finally I said, "you're left-handed aren't you." He confirmed that but didn't realize why that made a difference. I told him that for a righty, the operation was easier from the right. Then I asked him if he made all of his fellows stand on the left. He stared back at me...then he chuckled and said, "no wonder why they all have such a hard time. I've never really thought about that."

My point...Sometimes people forget that there are different ways to do things and that their way may not be the best for everyone. Don't be a slave to dogma.

 

[FliteSurgn]

Here's some examples of some not-so straight forward colorectal cases that I wouldn't feel comfortable with by the second year (I have actually seen these since finishing residency in June)

...a locally advanced colon cancer growing into the abdominal wall and retroperitoneum which involves the ureter

...An obstructing tumor at the hepatic flexure that has invaded the duodenum

...A near obstructing right colon cancer in a patient that just perforated his stomach from a gastric outlet obstruction. Oh yeah, I almost forgot that he had a colovesical fistula from diverticular disease too.

...A tight stenosis at the splenic flexure in a patient s/p antrectomy and BII converted to a Roux-en-y who is on enough psych meds to make his colon look like a freaking anaconda.

Cool, huh.

 

[thenavysurgeon]

to dr evil:

i think your incredibly bold to state that you are comfortable with the cases you've listed...how can you be?

how many complications of LAR have you dealt with, personally. Leaks, strictures, local recurrences, pelvic abscesses...just to name a few of the complications from this one procedure.

does your program director know you are making statements such as the ones you are making.

dealing with surgical complications is exactly why surgery residency is 5 years long, and become a master surgeon is truly a lifelong endevour.

I would never, ever make the statement that I'm 'comfortable', even doing an appy, and I'm board certified. I can do the case, but I have respect and fear for the bad complications that these cases present...

you need to learn some respect and humility.

 

[fourthyear]

Dr. Evil's definitely had a lot of time in the OR, we can all agree on that. I am wondering - do you have PA's or NP's or just a super efficient hospital that allows you to spend so much time in the OR the first 2 years? Are you at a community program?

At my program,there's tons of floorwork, clinic, consults, etc. and we simply can't be sending interns to the OR all day every day. An effort is made to get junior residents in at least a few days a week, but there's floorwork, consults, and clinic (not to mention incoming traumas) to be done, so everyone can't be in the OR every day. How does your program do it?

 

[dr.evil]

to dr evil:

i think your incredibly bold to state that you are comfortable with the cases you've listed...how can you be?

you need to learn some respect and humility.

Oh Jesus People. How tight are your sphincters? This thread was not supposed to be a bashing of myself from all of those who are high and freakin' mighty on this internet message board.

I'm not finishing residency tomorrow, I still have 2 years 10 months of residency left, and I will never in my life deal with every complication of every procedure. You people are talking semantics here. Comfortable to me meant that straight forward cases would be doable without help. I didn't tell you I know all and I'm the be all god of surgery. I agree that my statement of "completely comfortable" was definitely the wrong words, in hindsight at least.

I'd call my partner in for most of the cases that Flight Surgeon presented, or even a urologist for the ureter case if needed. I would call them now in my training and I would probably call them my first year out in practice.

I'm comfortable doing an appy laparoscopically. I really feel I am. Will there be appys that I struggle on? Sure. Will I have complications? Sure. It's surgery. We're not perfect.

I said I wasn't comfortable doing an LAR yet. I'm just not, but I have dealt with the leaks post-op and intra-op, post op abscesses, and local recurrences. Granted, with guidance from staff or chief residents.

I'm not trying to be a cocky SOB. But at some point in you training, you have to have the balls to say that you can do a case. You don't miraculously realize that you can do cases right when you graduate but couldn't before. I'm not an idiot. I know I can't do every procedure every time at this point. The question was what should I feel comfortable doing.

Carotids doing greater than 75% = 19
Carotids doing less than 75% (i.e. 1st assist) = 8

I know I'm nowhere near the level of seeing every variability or complication of a CEA so don't slam me.

I've also done more than one EGD on colon interpositions, esophagectomies, roux-en-y's, B1 & B2s.

Guess what? It doesn't really matter what I'm comfortable doing at this point. I still have to finish residency. Then I can be some sort of god on the SDN forums.

NavySurgeon, please let your patients know that your not comfortable doing their appy prior to going to the O.R. I sure wouldn't want my surgeon to think that. Would I want him to be humble? Sure. Would I want him to be confident? Definitely.

I, without any doubt in my mind, fear every complication of every procedure I do. I thoroughly go over the most common complications with every patient on every procedure. It's 2am and I track down family to let them know that while putting in an IJ CVL I could drop a lung, hit the carotid and cause a stroke, cause bacteremia, hematoma, float a swan and burst the pulmonary artery, etc. I'm very paranoid. But I let them know that I've done many lines, am comfortable with them, but have not seen all of these complications personally.

Comfort with procedures is different than knowing that there are complications that are too big for you to handle alone and that you haven't done/seen it all.

I'm tired of typing and trying to justify my statement which has been misconstrued on another level. I will now retract my entire statement and say that I'm only comfortable with discharge summaries and am simply in my 7th year of medical school.

 

[dr.evil]

My program is a university based community program. No PA's or NP's. Great O.R. staff, social work and nurses. Zero and I mean zero true scutwork. We have very little downtime. We operate, see the next case, see a new consult, operate, repeat. Most of our discharge/scutwork is done before 7am. We don't round as a team usually and we rarely make afternoon rounds except in the SICU.

We usually have services in which 2 residents cover 2-7 attendings. That keeps you hopping.

Most of our numbers are pretty high. I told my chief that I couldn't believe he was letting me 1st assist on a carotid my intern year and he said "that's not chief case here". Probably a little over the top with that statement as I really believe that a carotid is a chief case but we do quite a few of these. Many of the residents graduate with >50 carotids (one graduated with 106 three years ago). I also think that all big belly cases are 4th & 5th year cases.

So what's the drawbacks? We get the minimum number of pancreas and liver cases and really don't do that well with pediatric cases (usually minimal primary surgeon numbers).

We miss out on the classic teaching rounds of old days where you walk around as a group and tell the attending/chief all the happenings. I learned a great deal from that method as a student.
I love operating and picked a place with the most operative experience I could find.

 

[Celiac Plexus]

So are you really saying that you're completely comfortable with your residency program?

Just wanna be sure.... that's a pretty bold statement.

 

[FliteSurgn]

Like I said, I didn't mean to pull your chain dr. evil. And I think that the only thing we really took issue with was the "completely comfortable" part of your statement because who knows when that straight-forward case is going to become not so straightforward (my examples). Those of us with more experience have seen those "easy" cases turn into complicated disasters more than a few times.

I'm glad that you are having such an awesome experience in the OR. Your residency sounds pretty similar to mine except we had more peds and probably a little less vascular. I always thought it was cool when the senior residents starting letting great cases filter through to the juniors because they had already done so many. And that is what perpetuates the early exposure that we enjoy. The only glitch that I hit in that system (in a small program) was if one of your seniors stopped letting things filter through. One of my senior residents decided that he REALLY liked thoracic, so he sucked up almost 80 cases. Well, that left little to trickle down. I had to hunt down a bunch as a chief when I would've rather been doing other cases.

Where I'm practicing right now (locum tenens at a VA while awaiting an active duty assignment in the military), we don't always have a urologist available. In fact, I have to take urology call when the urologist isn't around. However, I am completely comfortable partially resecting a ureter. At least when it is purposeful!

 

[dr.evil]

Sorry about all this. I let you guys pull my chain post call and a long week/weekend. You're all right. Completely comfortable is a little bold.

 

[Celiac Plexus]

Sorry about all this. I let you guys pull my chain post call and a long week/weekend. You're all right. Completely comfortable is a little bold.

Don't let the Man get you down!!!!!