As a large department, surgery is divided into multiple service teams. For four weeks of the rotation, you will be placed into one of the two main services--A Team or B Team. At times there may be several students on one service. Students are expected to work together cooperatively as young professionals.

The second four weeks are spent on the ‘selective’ portion of the rotation, which typically is two weeks on thoracic surgery and one week on vascular surgery and one week on breast surgery. When there are multiple students on the rotation, medical students may be placed on other subspecialty services. If students have special requests for their rotations, they must contact Anne Broyan at least four weeks prior to the start of the rotation. (See the General Overview section for further details.)

Third-year medical students will gain further experience in the field while also integrating with and participating in the team approach to patient care. Basic expectations for third-year students are the following:

Punctual attendance at morning and evening rounds with the resident team and active participation in the care of in-patients at morning and evening rounds with the resident team and active participation in the care of in-patients. 

Active evaluation of patients in the in-patient and out-patient setting, under supervision of residents and faculty in the in-patient and out-patient setting, under supervision of residents and faculty. 

Exposure to a variety of general surgery cases in the operating room. Core Topics and Skills that should be seen/obtained by each student are listed below.
Call - Each student will be scheduled to take overnight call with the residents four times over the four-week core rotation in general surgery. Each student should expect to take at least one night on call over a weekend, which will be set by the directors prior to the start date.

Participation, Expectations of Performance, and Grading
Medical students rotating on general surgery are expected to meet the expectations set from their home institutions. Each student will be evaluated by the team’s attending surgeons at the end of the rotation. It is the student’s responsibility to know and follow the learning objectives set by the home institution.

The department of general surgery at Geisinger Medical Center also has a basic set of expectations for students on service. The students must be familiar with this information from the start of the rotation.

1. Alert the attending staff and residents of any specific assignments or expectations from your home institution at the start of the rotation.

a. Students are excused from clinical duties for their final core examination as follows:

Temple University - Wednesday at noon at the end of the 8-week rotation.

PCOM- Thursday at noon at the end of the second month of surgery.

Etiquette
a. Attire/dress code

i. Always dress professionally

ii. Scrubs must be covered with a clean lab coat when outside of the operating room.

iii. Wear dress clothes, not scrubs, for clinic days

b. Always introduce yourself to patients and to anyone with whom you work (residents, attending staff, nurses, OR personnel, clinic staff, etc.).

Rounding
a. AM rounds tend to be fast and task-oriented to get the day started.

i. Obtaining vitals, fluid ins/outs, and labs.

1. The chief resident on service will discuss team work-flow.

2. Split-up tasks evenly with co-students.

ii. All data can be entered in the patient chart as start of progress note, dependent on chief resident preference.

iii. Only document physical exam findings obtained by your own exam.

iv. Medical students are expected to follow all patients on whom they assisted in the operating room or admission.

1. Maximum 4 patients per student.

2. The student should pre-round (including a full exam) on the patient(s) prior to morning rounds and document a note.

v. All student notes MUST be co-signed by a physician (resident or attending) on service.

Operating Room
b. The chief resident on service is expected to assign each student with surgical cases for the following day so that the student can adequately prepare for the case. Preparation includes reading the patient’s chart, understanding the pathology, and reviewing the pertinent anatomy for the proposed surgery. (Journal articles are also a good way to review the most up-to-date literature on a given disease/pathology. Also, the American College of Surgeons has an online textbook, which is available to all via the Geisinger Intranet. The link is www.acssurgery.com )

i. The OR (Operating Room) schedule is posted electronically in EPIC, under the title of "Grease board." The student can use this to keep track of the cases and know when the assigned surgery is scheduled.

c. In most cases, there should only be 2 assistants per attending surgeon in the OR (exception is MIS cases, which may have 3 assistants).

d. Introduce yourself to everyone in the room upon entering.

e. Foley catheter – offer to insert this any time it’s needed. A good tutorial can be found in the New England Journal of Medicine Videos in Clinical Medicine (http://content.nejm.org/misc/videos.shtml?ssource=recentVideos). This can also be accessed via the Geisinger Health Sciences Library via the Intranet.

f. IV – watch, learn, and try with the anesthesia team.

g. Arterial lines – watch, learn, and try with the anesthesia team (New England Journal of Medicine Videos in Clinical Medicine).

h. Orotracheal intubations – watch, learn, and try with the anesthesia team (New England Journal of Medicine Videos in Clinical Medicine).

i. Skin closure – Ethicon’s Wound Closure Manual can be helpful in learning this skill. Practice tying knots outside of the OR and ask your residents to show you how to suture properly.

j. Keep a case log.

The Work Schedule
k. Clear any and all absences with Dr. Facktor. You also may contact Anne Broyan, the Surgery Clerkship Coordinator, as well.

l. 80 Hour Work Week / Call Schedule

i. You will be assigned to take call approximately every sixth night.

ii. Every student should take one call on a weekend day.

m. In general, the students are released from clinical duties at noon post-call.

n. On rare occasions, the students may stay past noon post-call if there is an unusual, educational case in the OR (no more than once per 4 weeks).

o. When on call, notify the mid-level resident between 4-5 pm.

i. Give him or her your pager number so that you can be called for consults & cases.

ii. Working with the mid-level on call will likely be more educational than shadowing the intern, since the intern is usually focused on completing floor work or taking patient calls.

p. The students must keep track of their call schedule.

General Reminders
q. Work as a team with fellow students and the residents.

r. Often, you will be on a rotation with students from other schools.

s. Share your knowledge and help each other to make it the best experience for everyone (surgery is really a team sport and can actually be fun).

Lectures/Didactics
t. Tuesday Afternoons 2 to 4:30 pm with Dr. Pierce, held in the Cardiothoracic Vascular Surgery (CTVS) conference room located off the M elevator, 4th floor.

u. Wednesday resident lectures.

Clinic
v. Always dress professionally.

w. The attending staff will be on a relatively tight time schedule. Ask each attending how you might best help them, but also think of what you need to learn from the clinic experience.

x. ALWAYS introduce yourself to patients and to the clinic staff.

y. Practice and refine your History & Physical Examination skills.

z. Learn the routine post-operative check for surgery, with a focus on wound healing.

aa. Learn typical disease work-ups, with a focus on those which are common.

bb. Learn why or why we don’t operate (surgical judgment).

cc. Try to learn how to properly obtain informed consent for any procedure.

dd. Learn the pre-operative routine.