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Starting Surgery Internship advice

Discussion in 'Surgery and Surgical Subspecialties' started by tadalafil15, Mar 8, 2009.

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  1. tadalafil15

    tadalafil15

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    Feb 5, 2009
    Hey folks,
    Do you have any advice for starting internship year? i.e. good books/managing time/how to present yourself to attendings etc./ surviving call or real medical issues ( I feel unprepared from my med school days)

    Thanks.
     
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  3. rmarchigiani

    rmarchigiani Ciao Bella... 5+ Year Member

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    I second this....im going to have 3 months off after I finish school and before I start residency. Besides taking it easy before I get thrown to the wolves....what do you guys recommend as a good reading source?
     
  4. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

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    Besides getting your crib in order (no time once residency starts) and getting all of you license stuff done, I recommend restful and relaxing reading of any of the basic science sections of the big three texts (Sabiston's, Schwartz or Greenfield). Your first ABSITE is strong on the basic science so reading the first few sections of any of these books (choose the one that your program uses) is a good base and gets you in the habit of regular reading (something that will be difficult when you are post call and tired).

    I also strongly recommend starting (if you have not) a good 30-45 minute workout routine (3 to 4 times a week) that your body is used to by the time residency starts. Residency when you are physically and aerobically fit works much better than when you are not physically fit. It's very difficult to get something started once you start working but not so bad if you already have a good physical conditioning base. Be sure to get your abs as strong as possible.

    I love Mont Reid for a "carry around" pocket book along with the tiny "Survival Guide for the Surgical Intern" by Chamberlain. Both of these books can keep you "on point" for those day to day things that you need to get used to doing fast (dictating, writing orders etc). It doesn't hurt for you to review some CT scans and radiographs so that you can easily recognize pneumos, bowel obstruction, volvulus, proper line and tube placement, tumors etc. Go on line (UVa has a good site) and review some of this stuff.

    The rest of your time should be resting and relaxing because you won't have much of that once your PGY-1 year starts. Good luck and enjoy.
     
  5. rmarchigiani

    rmarchigiani Ciao Bella... 5+ Year Member

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    Thanks a lot for taking the time to post that very helpful information. Everything you said makes a lot of sense and im happy to say that ive already begun a lot of it. Once I match, I will contact the program and see which text to get, and Ive been trying to get as much practice with CTs and Xrays as possible.

    Working out is something I already do religiously, but the problem for me is going to be cutting back my workouts considering I go 5-6 days/week, roughly an hour to an hour and a half each day. But Ive already looked into it and started to get an idea of what i can do to be more time efficient in the gym.

    As far as resting and relaxing goes.....I plan on doing as much as possible in the next 4 months. I just want to clear my my mind so I can be as mentally and physically healthy as possible when July 1 comes around.

    Thanks again....:thumbup:
     
  6. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    FYI:

    Do not buy a major surgical text before starting internship. Many programs buy one for their categorical interns, or give you a book fund to do so. Buying it out of pocket before you start doesn't make sense. Borrow the book from the library or a friend.
     
  7. rmarchigiani

    rmarchigiani Ciao Bella... 5+ Year Member

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    Awesome advice, thank you. Thats a relief especially since I'm broke as of right now and those texts are expensive!
     
  8. waxedapathetic

    waxedapathetic 2+ Year Member

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    would reading cameron's book on surgery be alright? my impression is it is more readable and clinical than the big 3 texts.

    anyone have a viewpoint on this?
     
  9. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

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    I found Cameron more useful after I had completed PGY-2 year when I had more clinical experience. It was a great book for the senior-level ABSITE.
     
  10. dynx

    dynx Yankee Imperialist 10+ Year Member

    It is more readable and clinical. Unfortunatly, your goal should be to master the basic sciences. Strong knowledge in basic science means higher junior ABSITE score, means every other aspect of your life becomes easier. Thats far more important than easier reading during the period of your life since you decided to enter the medical field where you have the most free time.

    On another note. I disagree with the above posters about not buying a book now. I bought Greenfields (the best of the big 3 in my opinion) my fourth year and began to read from front to back:
    1. Its only 300 dollars
    2. I enjoyed reading it because I could do it at my own pace...nobody was making me, yet.
    3. You'll have a huge leg up in terms of your knowledge when you start your internship.
    4. If you don't do it....someone like me will have, and you will be compared to other residents. First impressions last and last and last. If you start out strong you'll have a reputation for being "smart/strong" that will carry you through rough times.
    5. at least where Im at the book allowance isnt dedicated to a single book. my program uses greenfields, I had it...so I bought mastery of surgery instead. Didn't loose anything.

    Number 4 above warrants special mention. START STRONG:
    1. Do easy things now like reading, really getting procedures down (lines/intubations) during your rotations that will make you look strong from day 1.
    2. Be the first intern in the door and the last to leave. You don't have to be that guy for five years, although you should be. Just the first 5 months. The perception that you're the hardest working intern will last almost regardless of what you do after that.

    Your reputation as a strong resident will keep people off your back, will gain you respect (not real world kind of respect but the kind of respect where people don't berate you daily, which in surgery is a grand thing). Day to day functioning becomes easier, you find it easier to keep up and read...and the cycle repeats.
     
  11. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    dynx...I agree with everything you've said. Its worth repeating.

    However, "only $300" may be a lot of money to someone, especially if they end up buying a book that their program will give them for free.

    No one is advocating that the OP not study or read at all. But IMHO buying a book without knowing whether you will get that specific book for free, is a waste of money. He should be able to borrow the book from friends or a medical library or at the very least, wait until match day and see what the home program book is.

    Finally, in response to above. I love Cameron but its too clinical for junior residents and interns. Read it as a supplement but your junior ABSITE is basic science for which Greenfield is a better choice.
     
  12. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator Emeritus 10+ Year Member

    OK, I'll bite.

    Don't study. Really. How many more months of your life will you live without a pager or responsibilities? Seriously. Go skiing. Lay on the beach. Go to Europe. If you're really adventurous, go to Southeast Asia. Have fun while you can, because on July 1 you'll be strapping on a pager that lasts for the next forty years. Seriously.
     
  13. Sarcophageal

    Sarcophageal Intern 2+ Year Member

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    I guess I am adventurous, I will be going to SE Asia for a month. I am just going to read Cope's and a Trauma Manual. I have been told nothing will prepare you.
     
  14. Samoa

    Samoa Physician Pharmacist 10+ Year Member

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    Speaking as someone who did NOT have a chance to get away and relax between med school and residency, I agree with the above. Sure, review whatever you have lying around from your surgery clerkship, but don't shortchange your vacation time to do it. Give your brain a total break from thinking about medicine, for as long as your personal level of neuroticism can stand.

    Internship is 10X more painful if you aren't at least starting the year fully tuned and recharged.

    (But if you absolutely MUST review something, wound healing is your best choice, followed by trauma, gut physiology and chest and abdominal radiology)
     
    Last edited: Mar 11, 2009
  15. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    Ok, smarty pants...no one ABOVE was advocating it.;)

    I think if anyone searches my previous posts you'll see I also advocate getting some rest in before internship but dynx's points about setting a good example from the start are to be heeded. Those first impressions are hard to overcome.
     
  16. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator Emeritus 10+ Year Member

    I agree about first impressions being important. I think most of those first impressions will be related to work ethic, knowledge of your patients, and attitude. Your ability to answer the basic science ABSITE questions on July 1 will not be a major player in the reputation that you establish.

    It's been several years I've been exposed to General Surgery, but at my program (and those of my friends at several places around the U.S.), there will be LOTS of oversight in the first couple of months for any sort of procedure, followed by a graduated level of responsibility for things like lines. The only intubations that I performed as a resident were in the OR when I was on my Anesthesia rotation, although I came close to doing an emergent surgical airway as a PGY-3 (Gas got the airway after several attempts).

    Go have fun -- it's your last true break from true responsibility.
     
  17. surg

    surg 10+ Year Member

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    Dynx's advice is excellent on making a great first impression. It's hard to shake a bad first impression, so being lazy or uninformed are all quick ways to have this follow you the rest of your life.

    Good impressions can be made by doing good work from day 1. To that end, here are my thoughts:

    1) Always be willing to help out your team and your patients. No task is too menial, no job is too small for you in internship. The person who jumps up to help when needed, is remembered in a good way.

    2) Anticipate the needs of your team and patients. Don't wait for it to hit the fan before you spring into action. Try to always be thinking a step ahead. Being proactive, especially when you are on call will pay dividends. I always rounded by myself around 11PM when I was an intern on all my patients. Talking to the nurses about each patient before I took a nap, yielded MANY more uninterrupted hours of sleep and warded off a lot of problems. It also allowed me to talk to my chief before the wee hours of the morning if I saw a problem developing that I wasn't sure of the best course of action.

    3) Take every opportunity to learn. Don't shy away from things you are bad at. Your co-intern is slick at lines and you aren't? Don't assign him/her the lines to make it easier, keep doing them until you can do it. Not comfortable closing an incision yet? Don't give it to the student to make them feel good, get good yourself, then you can teach them later when you are competent. Renal failure makes you nervous? Read about it until it starts to make sense.

    4) Learning doesn't stop in the hospital and doesn't have to only be on your patients. I practiced incessantly at home the technical skills of cutting and sewing, whenever anyone else was presented, I worked to think about what I was going to do on that patient before the chief said anything to check my knowledge. Go to grand rounds, journal clubs, and teaching conferences of other services that you aren't on whenever time permits. Many of them are in the hospital in the evenings when you are on call and have to eat anyway.

    5) Be Honest. Faking it isn't going to help you learn, is potentially dangerous to patients, and when exposed will jeopardize your career. Interns that are ignorant are teachable, interns that can't be trusted are expendable.

    6) Be Nice. Treating your fellow physicians, nurses, and supporting ancillary staff well, will make it easier for them to help you out when you have the inevitable bad day. Yelling feels good, and occasionally is even necessary to garner someone's attention, but should not be routine, so that if you do it, it has maximal effect.

    7) Take care of yourself. Exercise/ Nutrition/ Friendships/ etc. are all important. Figuring out a way to survival the physical and mental toll of internship is up to you. Watch for burnout. Seek help from your friends, families, or a professional when you need it. You will not be the first person to want to quit, or the last. Most of us got through that and made it out the other side.
     
  18. njbmd

    njbmd Guest Moderator Emeritus 5+ Year Member

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    I didn't have a good aerobic base when I started residency. It took longer for me to get that aerobic base and lose some of my medical school weight. I applaud you for keeping yourself in shape.

    One of the things that I do now, when I can't get to the gym (even when traveling) is to make sure that I walk/jog at least 8 floors (not flights) up of stairs. I can find stairs anywhere and have been known to run the stairs in the parking garage. I keep a running tab on my Palm.

    My hospital has 14 floors so I can get a good workout in short order. It's better than nothing at all and it relieves stress for me. I meet plenty of folks in those stairwells too (just don't take any money with you). :eek: I make my "gym" whereever I can find it. I have strong legs and work my abs in my call room.
     
  19. Samoa

    Samoa Physician Pharmacist 10+ Year Member

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    I may take some fire for saying this, but your most important job those first few months is managing your senior's anxiety about the possibility of you screwing something up royally because you don't know what you're doing, and didn't talk to them first. So even if you have things under control, still talk to your senior every so often just to reassure them that all hell is not breaking loose and you're not going rogue with anything important.

    Try and get a sense of how long a leash your senior has. Because it varies, based on how competent they're perceived to be (which may or may not have anything to do with how competent they really are). And if theirs is short, they'll need more info and more frequent updates, even if there's absolutely nothing going on.

    Sometime between those first few months and the last few months of intern year, people will start to pay attention to whether the decisions you make are actually any good or not. This can save you to some extent if you didn't get the memo at the beginning. But frankly, poor judgment at this point hurts your reputation less than a poor first impression.

    Reading beforehand will help you get the most educational value out of your intern year, which will pay off on the ABSITE. So it's definitely helpful. But it'll be your work ethic and how well you work the hierarchy that establishes your reputation those first few months. And if you started out well, AND do well on the ABSITE, AND prove to have good judgment, then you're set. Which I'm guessing is dynx's situation, even if s/he ascribes it to studying beforehand.
     
  20. ikemae

    ikemae Nashvillian. Researcher. Thoracic Surgeon. 7+ Year Member

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    I think every fourth-year medical student, regardless of specialty, should see this post before they start. And assuming I make it through internship, I am totally going to use this when I become an senior resident/attending.
     
  21. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    Having seen this happen myself, it is true.

    Residents have been fired for being liars or being untrustworthy regardless of their knowledge base or skills.
     
  22. Dr Jboo

    Dr Jboo 5+ Year Member

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  23. JMarshall

    JMarshall 2+ Year Member

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    A little premature for this piece of advice, but when you start, realize that there is a huge difference between ordering something (labs, films, meds), and getting something done. Especially U/As. No one wants to handle urine. I remember being a med student last year and thinking everything you ordered just magically happened. turns out it doesn't work like that.
     
  24. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    Here are the steps:

    ordering something
    verifying it was done
    checking the results
    doing something (if needed)

    Many residents, myself included, forget that ordering something isn't the same as doing it and having it done doesn't matter if you don't know the results and take any needed action. I learned quickly as an intern that saying "It hasn't been done yet and I don't know when it will be" is not the right answer when the Chief asks about the CT scan ordered on am rounds.:laugh:
     
  25. cbass1350

    cbass1350 5+ Year Member

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  26. tadalafil15

    tadalafil15

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    Wow, thanks guys, I didn't realize I would so much input. One more question, besides heavy textbook, what handbook should I plan to carry? I was looking at Washington Manual for surgery vs. internship suvival guide.

    thanks
     
  27. rmarchigiani

    rmarchigiani Ciao Bella... 5+ Year Member

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    Thank you for the compliment. I think my discipline all stems from my 14 years of hockey and 6 years of lacrosse. If i miss a day in the gym...i get very crabby and feel like crap. However, with residency just around the corner I'm finding ways to cope with missed days and finding ways to make up for lost time or just combining days so I dont have to go as many times to get done what I need to get done. In the end, it all works out somehow. Not to mention, Im definitely going to be taking your advice about the stairs and the call rooms.

    I use to convince people to take the elevator with me because I was trying to conserve energy for my workouts, but now Im focusing more on taking the stairs in case I cant make it to the gym on a given day.
     
  28. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    I like the Mount Reid Manual.
     
  29. How much of this advice applies to 3rd year med students. I have my surgery rotation in Jan and Feb of next year (after having had 10 wks of Medicine, 2 wks of EM, 6 wks of Psych and 6 wks of OB). Because surg isn't my first rotation I'm not worried about needing general "team" advice (make your interns look good, look/be busy), but is there anything "surgery specific" I should know before starting?
    Thanks so much!
     
  30. Winged Scapula

    Winged Scapula Cougariffic! Staff Member Chief Administrator Administrator Physician Faculty Lifetime Donor Classifieds Approved 10+ Year Member

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    A couple of things I thought of a few days ago that I needed to mention to the medical student in my OR:

    - when being asked about anatomy, don't respond, "I don't know, its been 2 (or however many) years since I had anatomy." The attending's anatomy course will always have been longer ago than yours (as it happened, my surgical assist that day was a retired Ob-Gyn who said something like, "its been 39 years since I had anatomy and I still remember the name of that structure!" :laugh: )

    - there is something to be learned from every case. Please do not tell me you've seen this "like 3 times before" when asking to do a different case.

    - learn to walk faster

    - bring some food in your pocket; you may not have time to eat before the OR

    - do not eat in front of your residents who may not have time to eat or even sneak a granola bar (but then your mother taught you it was rude to eat in front of others anyway, right?)

    - do not wear your stethoscope around your neck or on a belt loop holder; put it in your pocket

    - on services with lots of dressing changes (ie, vascular), keep some trauma shears, dressing materials and tape in your lab coat pocket (some teams have a cart); run ahead of the team to the next room and take the dressing down

    - describe the characteristic of what's coming out of the drains; the amount is nice, but if you don't tell me its succus I might be a little peeved

    - learn how to suture, remove staples, remove drains, strip drains and everything you can about normal post-operative wound healing. Even if you don't become a surgeon, these skills may prove helpful in many other fields.

    - get into the OR before anyone else; help the patient move over to the table, put in the Foley (if needed and if so, without asking...unless its your first time), write your name on the board so the circulator can note it, get out your gloves and gown for the scrub nurse/tech, page the resident when the patient is in the room, help position, do not complain about your arms/shoulders/neck, etc. hurting during the case, if you must leave to puke/pee/whatever please give us notice so we can adjust retractors, assist in moving the patient back to the bed after the case, go to the PACU with them, offer to write the post-op note, do the post-op check on your patient...

    - try to be present for at least one end of life discussion with family; there are two types - the elderly SICU patient and the young trauma patient. These are totally different conversations with different reactions and it can be helpful if you have a good resident or attending who handles these and teaches you how.

    - there's always more, but this is a start...(and I'm sure we've got some threads here or in Clinical Rotations about this very topic)
     
  31. Dr Jboo

    Dr Jboo 5+ Year Member

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  32. jc7721

    jc7721 Member 10+ Year Member

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    This is GREAT advice. Every 3rd year, and especially 4th year, should take note of these comments.

    Your evaluation starts the day you arrive. Sure, everyone knows you are new, but they still evaluate your performance. Those monthly/bi-monthly resident evaluation meetings that attendings have don't go on hold your first day. You do not want to get a label of being slow/lazy/incompetent/slow learner/disorganized early on in residency. And you should know by now if you are at risk for being labeled like this (note that board scores do not account for any of these traits).
     
  33. Taciturngosamer

    Taciturngosamer 7+ Year Member

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    First, nothing will prepare you. Sure you've walked around the last four years thinking to yourself: someday I'll be the doctor. Then July1 comes around and all of a sudden you go from being joe q medstudent to Dr. Q. I think nothing freaked me out more that first week (except maybe a little SVT episode which I still like to block) than being called Dr.

    Boxes are your friend. Color coated boxes are extreme and for those who can manage to hold on to more than four pens at a time. But the little black ink boxes make sure you aren't putting your patients into little wooden ones because of some stupid intern level mistake.

    Make friends with the nurses. They can make your life a living hell from which there is no escape or they can give you a break when you are having a royally bad day. But never trust them either way.

    Sometimes you will make people dislike you in the interest of your patient. It should be expected and not taken to heart.

    If you are on call at night and a patient is having an issue: First, do the basic work up. Second, call someone more important. You shouldn't stare at someone who is post op day 0 for 6 hours while their heart rate clips away at 150 as you try and figure it out without calling someone more senior. Third, document that you called someone higher up than you. Which brings me to my next point:

    It didn't happen if it isn't documented in the chart.

    A stat ABG with CBC, chemistry, and lactate takes about 10minutes to collect and be processed. A stat cbc can take 30minutes at my institution. 20minutes is a very long time when someone is trying to die.

    The decision to intubate is a clinical decision. Do not wait on lab values or chest films to call your senior if you think someone needs a tube. BiPAP can buy you time before they call you back and you should make every effort to allow the senior/chief/attending to make the intubation decision (aka page the world). But nothing is worse than watching an urgent intubation turn into an emergent intubation.

    Chest tubes do not require x rays prior to placement. Know the basics of how to put them in before your start a thoracic surgery rotation.

    "Just do the right thing" is a motto that will keep you out of trouble for the most part and let you sleep at night.

    You will hate your job, the match, your chief, your institution, your life at least once in the first month. It gets better once all the boxes are unpacked.

    Go out with the group of strangers you meet in July. They will be your best friends soon even if you seem to have nothing in common.

    You will change as a person over the next year.

    You will become less tolerant of the little old lady who pays in pennies at the checkout line. You will have a giant pile of laundry that never seems to get done. You will be lonely. You will probably gain five pounds and drink more often. You will want to kill the third year medical student who spills coffee all over you and five minutes later says that you're not a real doctor because you didn't go into primary care.

    So: don't forget the people who really matter in your life. Be nice to your SO and remember they are putting up with a lot of crap on a daily basis from you. Call your mother weekly to let her know you are still alive. Have cookouts. Go to the movies and remember it isn't all bad.

    You will learn how to diagnose someone five seconds after walking in the room. You will be the person that a daughter comes to thank for taking care of her mother. You will learn how to juggle 40 patients and be efficient at it. You will make lifelong friends. You will find that you are stronger as a person than you thought you were.

    Ultimately though (and the disclaimer is that I am only an intern):

    A good intern knows that their job is to pay attention, write things down, follow up appropriately, and call someone more important if needed.

    Have fun over the next couple of months. Relax and enjoy the last few moments when you don't have any real responsibility at work.

    Finally, at worst, intern year really does fly by.
     
  34. rmarchigiani

    rmarchigiani Ciao Bella... 5+ Year Member

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    Amen!


    ......and I mean that with the utmost respect. Thank you for that post.
     
  35. ikilledfred

    ikilledfred 2+ Year Member

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    What do you guys think of studying for and getting Step 3 out of the way before starting internship?

    I just started doing some casual studying for it (ie. USMLEWorld and NMS books). My thoughts on doing so are kind of three-fold:

    1) I won't have to deal with it later
    2) I may not start internship as a surgical mastermind like I might if I were to read through Sabiston or Greenfied, but at least I'll be fresh on basic surgery info and the medical issues affecting my surgical patients (So many times during my 4th year surgical AI's I got pimped on such topics and I felt like that was where I impressed the attendings)
    3) taking this more relaxed approach to getting ready still gives me time to hang out on the beach!

    The only other thing I had planned was hammering out ATLS preparation.

    Any thoughts?
     
  36. twood

    twood PGY-5 5+ Year Member

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    i didn't think you could take step 3 before 9 months of internship??
    check on this before studying!
     
  37. ikilledfred

    ikilledfred 2+ Year Member

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    I'm a DO, I can register for our step three the day after graduation, so I'm in the clear there.
     
  38. Sarcoidosis

    Sarcoidosis 10+ Year Member

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    You can, only that you have to pick a state which does not have this restriction. There are many such states, example Delaware.
     
  39. nonbilious

    nonbilious 2+ Year Member

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    greenfield surgery.... everyone raves about the basic science and how its perfect for junior residents, But, is it too old, last edition was 2005, which means the info is at least from 2001, almost 8 years ago. I know its not popular, but I'm a 4th year (almost) and I want a book.... journals are just too scattered for me right now. I like greenfield, but the age is making me think about schwartz instead.
     

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