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Internal Med Knowledge In Surgery


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Sorry if perhaps this is a naive question to ask..

 

How much of your preclinical knowledge is relevant to your surgical specialties? I'm sure it'll vary depending on what field you're in, but can you share which internal medicine blocks are relevant to your specialty?

 

E.g. gastro is important for general surgery, but do you also need to be strong in endocrinology and cardiology to manage post-op diabetes and cardiac complications? or is that the job of the surgery ICU team

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oh haha at one of our hospitals we have a medicine ICU and a surgery ICU, so all the post-op patients are sent to the surgery ICU.

 

Ok, so we should have good knowledge in cardio and resp. Any other blocks that are very important for surg? I would guess nephro as well?

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Likely not realistic to assume that there will be others responsible for taking care of one's postoperative patients, especially in smaller centres. In the academic centre I was at, only the sickest patients went to the ICU. The rest were on the ward, which included a set of high-intensity monitored beds managed by the surgical team.

 

You can consult others for help, but the more knowledgeable you are, the more fulfilling your interactions, and the more respect you'll have from the people you consult. It's often obvious from the questions asked as to whether someone has familiarity with the issue or area they're submitting a consult about. The point of nephro block is not to make you a nephrologist - it is to give you a basic vocabulary and exposure to renal issues that you can build on later in your clinical training.

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Ya that's true, I don't think all the post-ops are sent to the surgical ICU.

I guess what i'm trying to ask is, if you want to perform well on a surgery rotation as a medical student, which blocks should you focus on reviewing? Obviously if you're doing a neurosurgery rotation, you'll review neuro pathologies. But in terms of the basics of surgery, which internal medicine topics should you know well? I,m guessing HF, ACS, desaturation, AKI...

Unfortunately I have an elective in surgery before my general surgery block, so just trying to figure out how to best prepare for this..

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Ok, that's a different question then. Why don't you read a surgery-focused book like Mont Reid or Surgical Recall? The first sections of both these books are focused on perioperative topics such as fluids, electrolytes, infections, respiratory issues, etc. from the surgical perspective - probably more focused and relevant for your rotation.

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I'd do surgical recall and focus on topics relevant by to general surgery that you are likely to be asked during a gen Surg elective (if your elective if feb surg). Stuff like borders the inguinal canal, management of the acute appy and blood supply to the colon. That's what you'll be pimped on. People aren't going to pimp you on stuff like Peri-op fluids or CHF management.

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Agree with the others. During my general surgery rotation, my staff attendings and residents only pimp me on anatomy and surgery-related topics: temperature PO 1, inguinal triangle, anatomy structures in the OR.

When your patient has multiple co-morbidity in gen surg ward, we often ask internal medicine as consultant, or endo for diabetes.

Ya that's true, I don't think all the post-ops are sent to the surgical ICU.

I guess what i'm trying to ask is, if you want to perform well on a surgery rotation as a medical student, which blocks should you focus on reviewing? Obviously if you're doing a neurosurgery rotation, you'll review neuro pathologies. But in terms of the basics of surgery, which internal medicine topics should you know well? I,m guessing HF, ACS, desaturation, AKI...

Unfortunately I have an elective in surgery before my general surgery block, so just trying to figure out how to best prepare for this..

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Ah OK, thanks for the book recommendations! I will look into those. So as a medical student we don't need to know periop knowledge? We don't evaluate patients in pre or postop and make plans?

Most surgical teams round as a big group first thing in the morning before OR and clinic starts. As a med student your role in the group is generally charting or looking stuff up. The team needs to see a lot of people in a short amount of time and that's the most efficient way. It's not like IM where you are assigned a couple patients and you have a ton of time to sit around and think about them, then write a note.

 

For pre-op management it'll probably be seeing people in the ER, in which case people will care more about you're knowledge of how to manage the surgical problem.

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As medical students, you will be doing pre-ops. Those are fairly straightforward, and there are preop templates.

Let your residents know that you are interested in general surgery, they will let you do more in the OR, and perhaps let the other medical students do the consults or the preops. THe best place to know if you like surgery is the OR!

Ah OK, thanks for the book recommendations! I will look into those. So as a medical student we don't need to know periop knowledge? We don't evaluate patients in pre or postop and make plans?

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Hi, are you a preclerk? If you are you need to know this:

- as a med student, you are basically useless. You are basically not allowed to take decisions, the VAST majority of the time. You cannot prescribe. You basically don't do much without being watched over very closely, unless if it's a staff who worked with you a lot, who trusts you, or you're in a more rural setting, where clerks have a little bit more ''power''. 

- they might ask you to do pre op evaluations, but that's with IM, and you basically input a bunch of scores. At the end of the day, your staff takes the decision

For gen surg, you don't need so much IM. Surgeons, from my experience so far, don't really like medicine, and won't pimp you much on IM, especially orthopaedic surgeons.

The things that you need on a surgical service for IM on a day to day basis as a med student are:

- bleeding, PT PTT, is the person anticoagulated

- ion imbalances

- labs wise: K, WBC, Hb, Plt

- approach to delirium, approach to fever, Dyspnea, for cardio: ACS, SVT and VT, post op infections

On most days, you reaaaallly don't need to know much more than that, and you should realize that you pretty much always have backup: a junior, a senior, a fellow, or a staff.

You won't impress a surgeon with IM knowledge.

Expectations are fairly low for clerks. As long as you are able to take a good Hx, do a god Physical, have a decent DDx and a plan that makes sense, you're okay. It's basically the expectations of a clerk. So don't worry too much. All I'm telling you now is things I didn't know before clerkship that I wish I knew!

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Sorry if perhaps this is a naive question to ask..

 

How much of your preclinical knowledge is relevant to your surgical specialties? I'm sure it'll vary depending on what field you're in, but can you share which internal medicine blocks are relevant to your specialty?

 

E.g. gastro is important for general surgery, but do you also need to be strong in endocrinology and cardiology to manage post-op diabetes and cardiac complications? or is that the job of the surgery ICU team

I just realized that I didn't really answer you.

So to answer your question directly, from my experience so far, IM does not matter all that much for surgical services.

And everything you learn from preclerkship is relevant during clerkship. e.g. A staff in surgery pimped me on neurofibromatosis and Kikuchi. You will always get pimped on these zebras, but on a day to day basis, IM knowledge required for surgery is veeery basic. Of course, for gen surg, know crohn and UC because these are common knowledge.

For DM, most hospitals use a scale, so nothing too complex with that.

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The things that you need on a surgical service for IM on a day to day basis as a med student are:

- bleeding, PT PTT, is the person anticoagulated

- ion imbalances

- labs wise: K, WBC, Hb, Plt

- approach to delirium, approach to fever, Dyspnea, for cardio: ACS, SVT and VT, post op infections

 

 

I would be impressed with a clerk that had a robust approach to any of these things. 

 

Your main function as a clerk on surgery is to write scratches down at 6am that qualify as "notes". And see patients in emerg. Hold stuff in the OR. Occasionally staple or suture skin. And cut sutures with the appropriate technique. 

 

 

More broadly, you're meant to be able to perform a thorough and situation-appropriate history and physical. If you can take a stab at a DDx, all the better, but you're not expected to have all that together yet. 

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haha yes, as you can tell I'm a preclerk with my lack of knowledge of how rotations work (soon to be clerk though)

your responses give me a better idea of what is expected of a medical student though

 

Does anyone have specific advice for an ENT rotation?

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I would be impressed with a clerk that had a robust approach to any of these things.

 

Your main function as a clerk on surgery is to write scratches down at 6am that qualify as "notes". And see patients in emerg. Hold stuff in the OR. Occasionally staple or suture skin. And cut sutures with the appropriate technique.

 

 

More broadly, you're meant to be able to perform a thorough and situation-appropriate history and physical. If you can take a stab at a DDx, all the better, but you're not expected to have all that together yet.

I expect my clerks to be able to at least spit out a rudimentary DDx for most basic surgical problems (flank pain, abdo pain etc). For more complex stuff like ddx of a liver or mass, not so much.

 

Appropriate suture cutting technique involves reading the surgeons mind as to what is "too long" vs. "too short", the definition of which changes multie times during the case.

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As far as I know, there isn't any good book for general surgery rotation, but toronto notes and Netter's anatomy should be a good start.

 

Learn the basics (history and physical) before reading advanced stuff that you will most likely never be quiz on. A clerk having a good Ddx for basic problems (that have a logic link with the actual problem...) is very impressive, even if he don't know the management perfectly. You must know about appendicitis and cholecystitis before reading on Kikuchi (what the f... is that?). Seriously, if you know advanced stuff but can't handle the basics, it is not well seen and it is useless for you as well.

 

If you wanna do well in any surgical rotation :

- Know your patients very well, especially the patient in the OR. 

- Try to learn the specific anatomy of the surgery you will assist to

- Treat the staff with respect

- Asking before cutting ''Is this the correct lenght?'' is an appropriate suture cutting technique. 

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I would actually say, when staff and residents and OR nurses treat you with mean comments, try to learn to move on and ignore them!

Medical students are generally nice to everyone, we are at the bottom of the medical hierarchy. 

I hope that it won't happen to you, but you will get shouted at, belittled when cannot answer a hard pimp question. Don't take those negative comments too personally, ,and focus on the things you love in surgery.

It would be very hard to make a complaint during your rotation, try to do it after the rotation (if this ever happens to you).

As far as I know, there isn't any good book for general surgery rotation, but toronto notes and Netter's anatomy should be a good start.

 

Learn the basics (history and physical) before reading advanced stuff that you will most likely never be quiz on. A clerk having a good Ddx for basic problems (that have a logic link with the actual problem...) is very impressive, even if he don't know the management perfectly. You must know about appendicitis and cholecystitis before reading on Kikuchi (what the f... is that?). Seriously, if you know advanced stuff but can't handle the basics, it is not well seen and it is useless for you as well.

 

If you wanna do well in any surgical rotation :

- Know your patients very well, especially the patient in the OR. 

- Try to learn the specific anatomy of the surgery you will assist to

- Treat the staff with respect

- Asking before cutting ''Is this the correct lenght?'' is an appropriate suture cutting technique. 

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I would actually say, when staff and residents and OR nurses treat you with mean comments, try to learn to move on and ignore them!

Medical students are generally nice to everyone, we are at the bottom of the medical hierarchy.

I hope that it won't happen to you, but you will get shouted at, belittled when cannot answer a hard pimp question. Don't take those negative comments too personally, ,and focus on the things you love in surgery.

It would be very hard to make a complaint during your rotation, try to do it after the rotation (if this ever happens to you).

That sucks, where did you go to school? I can't remember ever being shouted at or belittled as a med student on a surgical rotation. There was friendly teasing about things like my lack of knowledge of obscure 80's pop that was played during ORs, but I can't recall ever being truly belittled or shouted at. I went to MUN by the way.
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I am from a Quebec medical school. I will not reveal which school exactly, for anonymity :) (tis the CaRMS season)!

Most of my colleagues in other med schools , have had some bad experiences in gen surg. It is not that the residents or nurses are inherently mean to make our lives miserable, but under very long working-hours and a competitive environment, it is easy to lose their temper and snap on med students

If you want surgery, make sure that you have a strong personality and don't take every thing too personally. That would be my personal advice :P

That sucks, where did you go to school? I can't remember ever being shouted at or belittled as a med student on a surgical rotation. There was friendly teasing about things like my lack of knowledge of obscure 80's pop that was played during ORs, but I can't recall ever being truly belittled or shouted at. I went to MUN by the way.

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