Operating on a friend

One morning during my surgery rotation, I looked at my list of patients and was shocked to see a friend's name scheduled for surgery later that morning. I went down to pre-op immediately after rounds, deciding that providing emotional support was more important than respecting her privacy. I'm glad I did because she really appreciated me being there for her. She expressly invited me to watch her surgery, even though I hadn't even planned to ask, so I accepted her invitation.

The moment my friend slipped into unconsciousness, I struggled against my habit, acquired out of necessity, of relating to the person on the operating table as just another body that needs to be fixed. The legs were spread open to insert a tube into the bladder; taking care to pad pressure points, the body was contorted into a position convenient for the surgeon; the surgical field was sterilized with a solution that turned the skin a robotic bronze hue; finally, everything was draped so all that remained of my friend was a rectangle of this bronze-colored skin neatly wrapped in thin plastic.

I cringed behind my surgical mask when the first incision was made. I cringed despite such measures that effectively obliterated any hint that the body on the operating table was a human being, let alone my friend. That initial discomfort passed quickly, though, as the laparoscopic camera entered the patient's body and I saw the familiar array of organs on the monitor. Looking up at that monitor further distanced me from my friend. Young or old, fat or skinny, we're all made of the same building building blocks and put together approximately the same way. Without consciousness, we're all just another body.

The surgery went well, no complications. It was over before I knew it. Perhaps the time flew by quicker than usual because I was so transfixed by this internal struggle of remembering who owned those organs displayed on the monitor. The surgeon, who I had worked with many times before, knew that the patient was a friend of mine. "Do you want to help close?" he asked me when the surgery was nearing the end. That was his way of acknowledging that I had broken my routine of always asking if I can help sew up. "No thanks," I replied, "I want her to have a perfect job." "We wouldn't let you close if we thought you'd be anything less than perfect," my resident said. Still, I passed.

With the procedure finished, the surgeon invited me to go with him to the waiting area. In a bland windowless room, I silently observed the conversation between the surgeon and my friend's loved-one, reassurances that the surgery went well. I was struck by the solemnity of the conversation. I was also impressed by the respect and appropriate emotion afforded by the surgeon throughout the conversation. This was the only time I had the privilege of being included in a post-operative conversation with loved-ones.

I spent more time than usual with my friend in post-op, holding her hand and telling her that everything went great. Later that day, after she had been moved to a room upstairs, I spent more time than usual checking up on her. The standard post-op questions about nausea and vomiting and urination and ambulation seemed less important; I stayed for more than an hour, visiting, quality time. Rounds the following morning were somewhat awkward as I had to balance my dual roles of friend and medical student, not being able to give as much time to my friend as I would have liked.

I wish that I was able to give all of my patients this VIP treatment. Even if I can't always carve out time to connect with my patients on a more personal level, I think it's worth remembering to go back to the bedside when I do have a few minutes to spare. Observing my friend's operation and caring for her afterward also highlighted how easy it can be to accept the sufferings of my patients as routine and how I must guard myself against that attitude.

Why I decided against surgery

Over the past 8 weeks, I have been giving serious consideration to surgery as a career. I love it. I love the OR environment, the immediate gratification of doing something tangible to fix a physical problem, and I think that I would be good at it. I've watched my surgery residents, imagining myself in their shoes a few years from now, jealous that they actually get to do the surgeries rather than watch from the sidelines. They work hard, really hard. All that hard work would be worth it, though, to do something that I truly love.

But I have other considerations in deciding on a career. A lot of introspection has led me to understand that I need to find a balance between my career as a physician and the rest of my life. I'm speaking mostly about a hypothetical family. This may be just an abstract concept right now, but I know that the importance I place on family now will only magnify when there's an actual flesh-and-blood family to care for.

It's an unfortunate reality that surgeons must sacrifice more in terms of family life than do most other medical specialties. However, most of the surgeons at my community hospital seemed to be able to find a balance between their professional and personal lives. My surgery mentor, for example, has six children! Even the surgery residents at this community program seemed relatively sane and well-adjusted. But the bottom line is that, even if I chose a community versus academic program (usually a more stressful and toxic environment), going into surgery would still require too much sacrifice from other areas of my life that I value.

This reasoning felt like a cop-out when I was first coming to terms with the realization that surgery is not the career for me. My wise older sister picked up on this sentiment, which I hadn't quite consciously expressed, offering me this advice: "Don't feel apologetic for choosing a career that allows you to find balance in your life. There's a difference between wanting to find a career that makes you happy in all areas of your life and being lazy."

At the beginning of this rotation, I laid out three questions to ask myself to help me decide if surgery is right for me:

• Do I absolutely love being in the OR? Yes.
• Can I see myself happy doing surgery when I'm 60 years old? Possibly, but the chances are slim.
• Can I see myself happy in any specialty other than surgery? Yes, I think so. Before this rotation, I felt pretty optimistic that that specialty could be pediatric neurology. It's still high on my list, but this rotation has made me a little less certain. I learned that I like doing things, that I do well with a mix of action and cogitation. I hadn't seriously considered anesthesia as a career until this rotation, but from my one-week exposure to anesthesia, it provides both action and cogitation.

Early mornings on surgery

As much as I enjoyed my surgery clerkship, I was just plain exhausted by the end. It turns out that the extra hour between 4am and 5am makes a huge difference in terms of being happy and well-adjusted. The early-early mornings and long hours in the hospital, without natural sunlight and little interaction with people other than patients or healthcare providers, had a dissociating effect that made me feel as if I was living apart from the rest of the world. In many respects I was, though in all fairness that is hardly unique to surgery.

I won't miss those 4am mornings. There's something about driving empty streets that made me feel like I was in a zombie movie, eerie and slightly unsettling. Maybe I had turned into a zombie myself but just didn't know it. Still, I appreciated those early-early mornings for being peaceful and silent, for having the city to myself.

I've already had a few days of "sleeping in" to a normal hour, and I feel like a new person again.

I'm done with surgery!

I'm done with surgery! I'm done with surgery! I'm done with surgery! Very excited. It feels good to have that rotation under my belt.

More thoughts to come about my surgery rotation as a whole.

Laparoscopically visualizing anatomic relationships

I recently observed a laparoscopic sigmoidectomy, the removal of the sigmoid colon. The patient's uterus figured prominently in the center of the screen. As the surgeons followed the left descending colon into the sigmoid colon and rectum, I noted that the large bowel tracked posterior to the uterus.


Flashback to a little less than a year ago when as a second-year medical student, lacking any meaningful clinical experience, I was taught how to perform a pelvic exam with a standardized patient. I remember being surprised at the time that a complete pelvic exam includes inserting a finger in the patient's rectum, the purpose of which is to check for cysts or fibroids on the posterior aspect of the uterus.

Afterward, I looked in Netter's to better understand the anatomical relationship between the uterus and rectum. I got it then, but it wasn't until this past week when I saw the actual anatomy directly from inside the abdominal cavity that I really got it.

Anesthesiology

The Surgical Care clerkship includes a one-week exposure to anesthesiology. Admittedly, I entered this week with considerable bias against anesthesiology. It's boring... All anesthesiologists do is put patients to sleep before surgery and wake them up after it's over... There's not much patient interaction... It turns out, though, that my prejudices against anesthesiology were wrong.


The primary job of anesthesiologists, medically speaking, is to keep the patient alive and stable, numb, asleep, and motionless, so the surgeons can do their job.

Anesthesiology is mostly applied physiology and pharmacology. It's the application that interests me. Anesthesiologists use drugs and the ventilator machine to micromanage a patient's vital signs for the duration of the surgery and immediately afterward. Physiologic changes take place right before your eyes. Push propofol and watch the patient fall asleep, completely unarousable. Push rocuronium and watch them stop breathing. Push phenylephrine and watch their blood pressure rise and their heart rate drop. Instant gratification.

Minor procedures are another component of the anesthesiologist's job description: placement of arterial lines and central lines, epidurals, spinals, and of course endotracheal intubations.

I couldn't get enough of the procedures. Over the past week, I placed my first arterial line (after one failed attempt), and my entrotracheal intubation record was 6 successful placements for 13 attempts. Pretty good for a third-year medical student, I was told by my anesthesiology mentor, but he was probably just trying to encourage me. An actual anesthesiologist needs to have a perfect record.

I was also struck by how happy and well adjusted everyone seemed to me. One anesthesiologist just got back from a trip to the Galopagos Islands, and another partners with a team of surgeons on regular missions to Africa. At lunch one day, we determined that all six anesthesiologists at the table were runners. My anesthesiology mentor actually runs 5 miles to and from the hospital a few times per week! I felt like I fit in.


Now, I'm left feeling more confused about my future than ever. I had to write out a list of pros and cons for anesthesiology:

Pros:

• Optimal lifestyle
• Lots of procedures
• Taking away pain makes people happy
• Instant gratification
• No rounds
• Work in the OR, get to wear scrubs to work
• Happy, interesting, and active colleagues
• Good compensation

Cons:

• Does not fit the archetype of a physician that I have carried in my mind since childhood
• No longitudinal patient contact and minimal face-time with patients
• Not the star of the show

Surgery is halfway over

That went by quickly. Mid-point gut check: I like surgery, I like doing procedures, I'm willing and capable of working the long hours required of a career in surgery, and I think I would be a good surgeon. But I'm still very skeptical about the lifestyle issue.

Feeling useful as a third-year medical student

During my last call night, I worked with an upper-level resident who treated me more like a sub-I than a third-year medical student. "Go get a history and physical on this new patient in the ED. I'll see you in 20 minutes." I can't emphasize enough how much I appreciate this management style. He gave me a clear task, he clearly communicated his expectations of my performance, and those expectations were appropriately high. I'll go out on a limb, here, but I think that I was actually useful that night. This is something to hold onto given that I have felt decidedly not useful during much of third-year so far.

Daylight savings

Another perk of being in the middle of my surgery rotation now:

Fall daylight savings. Tomorrow morning when I wake up at 4:15, it'll feel like 5:15. Too bad that effect wears off after a few days.

My experience in the OR so far

Once I got past the physical demands of standing in place for hours on end, I quickly realized that spending time in the OR observing surgeries is my favorite part of the surgery clerkship. Depending on the day's OR schedule and whether there are any didactic sessions in the afternoon, I might see anywhere between 1 and 5 surgeries in a given day. So far, I've tried to give myself a wide variety of cases, which represent the vast majority of bread-and-butter general surgery. These include:

• Laparoscopic appendectomy
• Laparoscopic cholecystectomy
• Colectomy with end ileostomy
• Ileostomy takedown
• Direct inguinal hernia repair
• Femoral hernia repair
• Epigastric hernia repair
• Thyroidectomy
• Breast lumpectomy

I've also had the opportunity to stand in on some surgical sub-specialty cases: laser transurethral resection of the prostate (TURP) with a urologist, vitrectomy with an ophthalmologist, biopsy of a posterior tongue mass with an otolaryngologist. I'm really grateful to have exposure to the surgical sub-specialties because I elected to do general surgery for all 8 weeks of this clerkship. I know that I don't want to be a urologist or otolaryngologist. I was fascinated by the eye surgery, though, and plan to observe more of them.


Here's a rough breakdown of what my OR time looks like:

50% - Standing quietly behind the attending or resident, trying to stay out of the way, and waiting to be pimped or rewarded for my good behavior with a gift from Above.
40% - Human retractor. Special features: Retracts 360 degrees along all three axes; Variable tension; Responds to verbal and tactile commands; Central processor allows for experience-based learning and adaptability.
5% - Sewing up laparoscopic port incisions or tying knots.
The remaining 5% - Split between driving the laparoscopic camera, electrocauterizing vessels, and other odd jobs.

Climbing the ladder

One of my surgery attendings likened a career in surgery to going through junior high school all over again, every few years. You graduate medical school thinking that, finally, you're climbing your way up the ladder, only to realize that you're just an intern. Interns are dirt: they take care of all the jobs that residents and attendings don't want to deal with and that medical students aren't allowed to do.

You progress through residency and think you're hot stuff by the time you're a chief resident, then you do a fellowship and realize that fellows are dirt, too, low suregon on the totem pole in that given sub-specialty.

Then you finish fellowship and get a job in the real world thinking that finally you've made it, except you realize that you're the most junior member of the practice. Everyone else is looking at you like, "So you think you're a surgeon now, huh? We'll see about that."

It's a recurring process of having to prove yourself to those with more surgical experience. Every few years, you'll be the new kid on the block who everyone picks on. Until you're old and gray, there will always be someone more senior who will serve it to you.

What I found most amusing about his analogy is that medical students aren't even on the proverbial ladder. This correlates strongly with what I've observed so far, that surgeons in general tend to avoid recognizing the presence of medical students except in the function of teaching.

Exhausted

I'm post-call today, meaning I just came off a 28-hour work day. Slept less than an hour last night. My resident called last night a 7 out of 10 in terms of how busy we were. It's the first call night I've experienced that is actually representative of what call is really like for interns and residents.

This was the fourth call night I've taken in 12 days. We have to take call a total of 6 nights spread over 8 weeks. I front-loaded on purpose for two reasons: 1) so I will have more time and energy available toward the end of the block to study for the departmental exam, and 2) to experience the exhaustion that surgery interns and residents have to go through taking overnight call every 3-4 days.

So, how did I handle it? I was surprised by how easily I stayed awake and alert when there was action, like when I had to get a history and physical exam from a patient in the Emergency Department or lay eyes on an unstable ICU patient.

I also noted with some sadness how I had much less patience for the circumferential responses my patients would give to open-ended questions like "Tell me why you're here tonight." What I really meant, I realized, was "Tell me why you're keeping me from sleep." Even as much as I wanted a busy call night, it's amazing how sleep deprivation makes everything except sleep seem much less important.

I hope that my impatience wasn't apparent to my patients in the way I interacted with them. This is something for me to keep an eye on in the future when I'm similarly exhausted.

Ironic, I thought when 4am rolled around and I had been working all night, that this is the time when I would have been waking up for the next day's work. It used to be much later. I learned that a half-hour "nap" before pre-rounds can make a huge difference in getting me through the rest of the morning.

Trauma at Denver Health

St. Joe's is a private hospital that doesn't see any trauma surgical cases, a competency of this clerkship. Surgery students at St. Joe's and other hospitals that don't get a lot of trauma are required to take overnight call once during the clerkship at Denver Health, a Level 1 trauma center.

I did my trauma overnight call at Denver Health last night. The Friday night before Halloween with mild weather. I was expecting (and was actually hoping for) a very busy night, but we ended up seeing just one trauma case, a stab victim.

I wished that I could have been one of the trauma surgeons: blood squirting on my gown, my arms elbow-deep guts, running the bowel to rule out perforation. The surgery was fascinating to watch, even banished as I was behind the curtain at the head of the bed in the anesthesiologist's corner, not scrubbed in.

I want to see more trauma.

Brevity

Everything about surgery, except surgery, is brief.

A prime example:

On rounds the other day, an intern was presenting a patient who I had seen the previous night. The surgery team was consulted to rule out ischemic colitis, which is a surgical emergency. As often happens, the chief resident interrupted the intern after about 2 minutes into his presentation and jumped to discussing the plan, all the while making movements toward the patient's room.

Since we had skipped the physical exam part of the intern's presentation, the chief turned to me as we were entering the patient's room and asked me, "What did you find on physical exam?" I knew that I had exactly three seconds to respond, so I said quickly, "Abdominal pain was not out of proportion to exam." The end.

Doctors use objective facts like physical exam findings and laboratory data to communicate opinions. In this case, I needed to tell my surgery chief, "I don't think this patient has a surgical belly," using one sentence summarizing my physical exam. That's a lot harder to do than it sounds, which is probably why my chief rewarded me with high praise: "I'm glad you said that; it's exactly what I wanted to hear."

The surgery routine

The early-morning routine:

0415: Wake up
0415-0440: Get dressed in clean scrubs borrowed from the hospital.
0420-0440: Eat a quick bowl of Cheerios and otherwise get ready.
0440-0445: Drive to the hospital.
0445-0530: Pre-round on 2-3 patients.
0530-0700: Rounds.
0700-0800: Morning lecture (Tu-Fr).

Mornings and afternoons:

My time after 0800 is surprisingly unstructured. Medical students are expected to sign up for surgeries in the mornings. In the afternoons, I tend to either sign up for another surgery, if there's something interesting scheduled, or find my intern and try (not always successfully) to make myself useful. On non-call days, I've been leaving the hospital around 1700-1800.

Evenings:

I grab dinner on the way home and watch some Daily Show or Family Guy while eating. Then I try to get some studying in before crashing. I shower at night, now, to speed up the early-morning routine. My entire schedule has shifted up a few hours so that I'm going to sleep between 2100-2200 for an average of 6.5 hours of sleep per night.

The on-call routine:

When I'm on call, the schedule is exactly the same except that I go to sign-out (when the day team hands off patients to the night team) at 1700. Then I tag along with the mid-level resident for the rest of the night doing things like putting in arterial lines and consulting on Emergency Department patients who might be surgery admissions.

This doesn't last all night. In the two times I've taken call so far, I slept for 5 hours and 4 hours. In contrast, my classmate got slammed with a busy Saturday night and only slept for 2 hours. It's really hit-or-miss.

Post-call:

On post-call days, I get to go home after morning conference and after I finish writing my progress notes. That's the end of a 28-hour work day. I head straight to bed and sleep for a couple hours, then I have the rest of the day free to relax, go for a run, write in my blog, and take care of chores like laundry and grocery shopping.

Going hungry on my surgery rotation

"Dude, you're going to lose weight on this rotation." So said a classmate and good friend who just finished surgery at University and also happens to share my ridiculously fast metabolism. After a week on surgery, is the food situation as bad as my friend said it would be?

I lucked out because St. Joe's has a decent cafeteria, gives out a monthly meal allowance, and on top of that provides free breakfast four days out of the week. Free food is a big deal.

Still, the surgery culture pervades. It's a badge of honor for surgery residents how long they can go without food and water. One resident was telling me that at Denver Health he regularly went a whole day with no food, two cups of coffee, and no bathroom breaks. That just doesn't seem healthy to me. Or pleasant. Yet I heard a certain amount of pride in the way he said it. This culture is self-perpetuating, passed down from resident to intern to medical student.

So as someone who needs to eat something every few hours, what am I doing to get myself through this surgery clerkship?

First, I have a protein bar on my body at all times. That can usually stave off hypoglycemia for another hour or so until I have an opportunity to eat something more substantial.

Second, I keep a protein milkshake in the doctor's lounge refrigerator. A few swigs of that can also keep me going for about another hour.

Third, I try to eat low glycemic index foods to minimize the blood sugar roller coaster. This means lots of fruits and veggies, scrambled eggs, and double-decker peanut-butter sandwiches on whole-wheat bread.

Fourth, if there's an opportunity to eat, then I take it even if I'm not really hungry, because who knows when I'll be able to eat next.

Surgery slumber party

I just finished my first overnight call ever, coming in at 5 yesterday morning and getting home at 9 this morning for a total of 28 hours. Surprisingly, the time went by very quickly. I helped my resident place arterial and central lines, and he let me aspirate a cystic mass. Very fun.

I didn't even feel too tired at 11pm last night when things calmed down and my resident told me to go get some sleep. Even more surprising is that I woke up almost immediately, with minimal grogginess, when I got a text at 5am from my resident to meet him downstairs. Perhaps most surprising to me is that I remained alert and for the most part engaged during breakfast rounds that lasted 1.5 hours.

It seems that a lot of my medical school experience is about dispelling myths that I "can't" do one thing or another, simply by doing them. Last night was admittedly a soft overnight call since I actually got to sleep for a few hours. But I took away from that experience two important lessons: 1) I can do it, and 2) It's not that bad.

Upcoming Surgical Care clerkship

I'm heading into my Surgical Care clerkship tomorrow with excitement and some nerves. Given how much I've talked with my classmates and other medical student friends about the surgery rotation, even specifically at Exempla St. Joseph Hospital (affectionately called St. Joe's) where I'll be working, I don't expect too many surprises.

I know that the surgery sub-culture is much more steeped in hierarchy and tradition than other areas of medicine. I know that I will be sleep-deprived. I know that I will be hungry. I know that my feet will hurt from long hours of standing in the OR.

But on the bright side:

The surgery program at St. Joe's is known for being relatively relaxed compared to other hospitals. My friend who just finished surgery at St. Joe's told me that the hours are for the most part around 12-14 per day, which is about what I was putting in on my Medicine rotation. St. Joe's is also well-known for feeding its medical students: free breakfast most mornings, plus a meal card for call nights. And I finally broke down and got a pair of Danskos to take care of my feet (thanks, Mom and Dad!).

So, at this point, is surgery still a possible career choice? Yes, with reservation. I want to experience the surgery clerkship before making up my mind one way or another. Throughout the clerkship, I will be asking myself these three questions:

• Do I absolutely love being in the OR? If the main source of happiness in my life is not being in the OR, then I shouldn't do surgery.
• Can I see myself happy doing this (or a surgical sub-specialty) when I'm 60 years old? An attending during my Medicine rotation told me that answering no to this question convinced her to choose internal medicine over surgery.
• Can I see myself happy in any specialty other than surgery? If so, I will be much happier doing that than surgery. I've heard this advice from numerous surgery residents.

Regardless of whether surgery turns out to be the right path for me, these 8 weeks will for sure be interesting.

Guest Writer: Thoughts on General Surgery

--Greg, University of Colorado School of Medicine, Class of 2013

I'm two weeks into my general surgery rotation. We are up pretty early taking care of patients and luckily get a lot of surgery time during the day. It’s hard being a third year medical student in the hospital. We have to be at certain locations throughout the day, but they don't give us the clearance to get into a lot of the ORs and other places we need to be. This makes it quite frustrating at times and we have to be creative in navigating around the system.

Today in surgery, my attending allowed me to close up a couple of the incisions. For a third year medical student, closing up the incisions is a big deal, it’s exciting and we actually feel a little bit useful. In reality, closing up the incision is not a big deal at all, but we take what we can get. The whole time I was closing, a scrub nurse stood behind me looking over my shoulder, ridiculing my every move. "I can't believe how slow he is", "Oh my God, you're wasting so much suture," "This is ridiculous, its going to take him an hour to throw four stitches!" "This is bullshit, I want to get out of here," "If you want to learn, GO TO DENVER HEALTH!", etc.

Finally when it was all done and we were cleaning up, she came over looked me in the eye and asked if I was going to need therapy, in a poor baby sort of voice. I held my own the entire time, trying to focus on the task and not let my emotions get to me. Even though she made a big stink the entire time, I think I did a reasonable job, and it didn't take an eternity like she would like me to believe.

Comments like those experienced today are frequent events, but they are not usually that harsh or direct. I've come to find that there is this unwritten rule that the third year medical student is a living punch dummy, free to be abused by everyone and anyone associated in the hospital. Surprisingly, the surgeons are the least likely of all the staff members to be mean to us. They poke a lot of fun at us, but in a respectful, often humorous sort of way.

I seem to be able to brush off the humiliation completely when in the hospital. Unfortunately when I get home, nonproductive thoughts enter my mind. Thoughts questioning my abilities, questioning if I will ever find a niche and be successful in a career in medicine. Sometimes I question the whole profession altogether. How can such a beautiful thing, taking care of the ill, be laced with such arrogance, animosity and uncooperative behavior? The medical students may be a burden to the nursing staff, as we often don't always know what to do and we frequently just get in the way, but I wish they understood the pitted feeling of anxiety held within our stomachs throughout the entire day. We want to be useful, we don't want to be in the way, and most of all we don't want to make anyone angry at us.

I entered medicine because I felt it was a special profession, one where everyone was held to the highest standards and mutual respect and collegiality were not only encouraged, but demanded. I guess every profession that holds a human element is not exempt from the fallacies of our species. It was naive of me to think otherwise.

Looking at the big picture though, I am able to realize that this is just one small hiccup in my training. Tomorrow is a new day. I'll probably get yelled at and made to feel inadequate, but it takes a strong person to get to this level and I will persevere through this as I've demonstrated in the past.

I will probably not be a surgeon. I like procedures, but I do not enjoy the culture that has become ingrained in the OR. I like the idea of working in a small clinic where I can have more influence in setting the standards of behavior and developing the culture of my practice. We will see though; feelings and interests seem to change rapidly in this training. Two weeks ago I was thinking orthopaedics, today of all things I'm considering outpatient skin cancer surgery as a sub-specialty of dermatology!