Resident Readiness General Surgery (3 page)

Assistant Professor of Surgery

Department of Trauma and Critical Care

Northwestern University

Feinberg School of Medicine

Chicago, Illinois

Chapters 18
,
38

Ezra N. Teitelbaum, MD

Surgery Resident

Department of Surgery

Northwestern University

Feinberg School of Medicine

Chicago, Illinois

Chapter 23

Anthony Visioni, MD

Resident, General Surgery

Univevrsity Hospitals Case Medical Center

Cleveland, Ohio

Chapter 6

Michael W. Wandling, MD

Resident

Department of Surgery

Northwestern University

Feinbrg School of Medicine

Chicago, Illinois

Chapters 45
,
57

Molly A. Wasserman, MD

Resident, General Surgery

Northwestern University

McGraw Medical Center

Chicago, Illinois

Chapter 43

Louise Y. Yeung, MD

Surgical Resident

Department of Surgery

University of California, San Francisco—East Bay

Oakland, California

Chapter 16

ACKNOWLEDGMENTS

The idea for this series came from watching a dedicated educator Dr. David Rogers create and implement a successful residency readiness course. So successful was this course that it was adopted across Southern Illinois University Medical School’s fourth year curriculum. It has been a joy working with my co-authors, especially Brian George, a devoted educator himself. He assembled a great group of case writers without whom this book would not exist. I am, as always, greatly indebted to my editor, Catherine Johnson, who believed in me and this series right from the very beginning, championing it on to production. I appreciate McGraw-Hill’s continued support as well. Finally, I deeply appreciate the continued support of my colleagues at SIU, which gave me the freedom to work on this book as I needed to. Most of all, I appreciate the support of my family, Phil, Wes, Boss, Aleksei, and Zory—I couldn’t have done it without you!

Debra L. Klamen

Section I.
Introduction

Welcome

Brian C. George, MD, Alden H. Harken, MD, and Debra A. DaRosa, PhD

We are excited for you! You are about to embark on an exhilarating journey that will be filled with fear, awe, pride, fatigue, reward, and fun. It will, in all likelihood, be a transformative experience that you will look back on with warm nostalgia. While we hope you too are excited about starting your residency, we also recognize that it may seem a bit daunting. You have, no doubt, heard a lot of fanciful stories about the surgical intern year, and you’ve watched some hardy souls weather the experience. But attending an opera or watching a boxing match is a whole lot different from singing or slugging it out in one.

When Columbus set sail for the New World, his destination on the map was blank. In between Spain and the edge of the world, some helpful cartographers penciled in storms and sea monsters. Like Columbus, you too are sailing into unfamiliar territory. And in surgery the storms and monsters are real enough. But while all people need to captain their own ships and embark on their own journeys, in this case the map is not totally blank. This book is just one of many resources to help guide your forward motion.

We have written this book with the goal of helping you, the soon-to-be-new intern, to develop a deeper understanding of all the “basics”—and nothing more. We have worked hard to keep this book as focused, succinct, and clinically relevant as possible. For example, the book does not include any information about how to manage pancreatic cancer, because as an intern you are never actually going to do that anyway. It does have chapters on how to replete electrolytes, how to triage multiple simultaneous admissions and/or consults, and what your role should be during a trauma. Indeed, we have focused on those areas where you might be expected to already know what to do (even if, like many new interns, you don’t). In some cases we simply explain the potential significance of various symptoms and signs, so that you will know when you should call for help.

But how did we come up with the final list of topics we wanted to cover? We started with the “prerequisite” knowledge that an expert panel at the American College of Surgeons (ACS) felt that all medical students should know prior to starting their internship. The list is long—too long. It includes a lot of topics that are already understood by 99% of medical students or not actually that useful in everyday practice. We didn’t want to include any of those topics, as that would be a waste of your time and needlessly decrease the signal-to-noise ratio. In order to help sort it out we therefore conducted a survey of “real live interns” during their fourth month of internship, while they could still remember what it was like on their first day. Using a structured instrument we determined which topics the interns wished they had known more about before they started their internships. We analyzed and ranked those responses, added our own 2 cents, and came up
with the book you are now reading. While we cannot guide you all the way to your ultimate destination, we feel confident that this book will provide you with a map that will get your voyage safely underway.

This introduction would not be complete without extending a hearty thank you to all of the authors who helped put this book together. We hope that you, the reader, will appreciate their selfless efforts as much as we do.

As a final note, we also hope you will write to us and share your comments and suggestions. Not only would it be fun to hear your reaction to our hard work, but it would also help us make improvements for the next edition. You can reach us by e-mailing [email protected]—we welcome your feedback!

How to Read this Book

Brian C. George, MD, Alden H. Harken, MD, and Debra A. DaRosa, PhD

The chapters in this book follow the same format and include multiple elements, all specifically designed to maximize your learning. Most chapters start with a case written in the second person. We expect these cases will help make the discussion more tangible and will emphasize the relevance of each topic to your new job. After the case, there is a set of questions designed to help you assess your own knowledge on the given topic. Well-established learning theory suggests that you should try to answer those questions before moving on, as doing so will help you retain what you are about to read. The answers to those questions can be found in the text of the case discussion that follows. After the case discussion you will find a set of questions and answers. Again, these are designed to help you assess your own knowledge, and to provide some repetition (as you probably know, repetition is the mother of all learning, and repetition is the mother of all learning). The last part of each case-based chapter includes a list of the most important tips to remember. If you learn nothing else from each chapter, you should try and remember the tips. A couple of days prior to starting your internship you could even flip through the book and review just these bullet points—they are incredibly high yield and can serve as a brief overview of the entire book.

The chapters are organized into sections:

1.
Introduction

2.
Handling Patients in the ED

3.
Handling Inpatients

4.
Handling Patients in Clinic

With the exception of
Section I
, each section is organized around one type of patient care. It should be emphasized that while each case takes place in a specific setting, the chapter as a whole will often discuss topics that are more broadly applicable. We trust that the reader who is using this book as a reference will, with the help of the index, be able to find those topics that are of most interest. For the reader using this as preparation for internship, the sequence of chapters has been organized to be read from start to finish.

General Advice

Brian C. George, MD and Alden H. Harken, MD

As you complete the final stages of medical school it is now time to turn your thoughts to that next stage: internship and residency. This chapter will introduce you to some common issues faced in that stage and give you some basic guiding principles.

A CASE OF THE JITTERS

We were all nervous when we started our internships. In fact, it would be frightening if you
weren’t
nervous—those are the interns who are dangerous! But you should also have some confidence not only in yourself but also in your co-residents, your attendings, and the system. You are not alone, and nobody expects you to know everything your first day. They
do
expect you to care about your patients and to do everything in your power to “do the right thing.” Often that means asking for help. Contrary to what you might think, an intern who asks for help is held in much higher esteem than the one who avoids calling (whether out of embarrassment, an inappropriate concern for the feelings of the supervisor, ignorance, or just plain laziness). The worst thing that somebody might think about you if you call is that you don’t know what you are talking about. And, well, there is some truth to that. Sorry. But the sooner you come to accept the limitations in your knowledge, the faster you will learn and the better you will be for your patients. Of course, there will come a point where you do need to start working through things on your own, but the first day of internship is not that time. Until then, try and revel in the excitement and awe that you are about to become a surgeon. You deserve to be proud. Just not too proud.

GETTING TO KNOW YOUR PATIENTS