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Core Surgery Clerkship
During the clinical years of the MD curriculum, medical students will complete a rotation with the Department of Surgery for 8 weeks. While on this clerkship, students will spend four weeks on a general surgery rotation, and the second four weeks will be split into two two-week rotations on the subspecialty services.
Surgery encompasses a diverse range of specialties and includes the following disciplines:
- Breast surgery
- Cardiothoracic surgery
- Colorectal surgery
- GI surgery
- Pediatric surgery
- Plastic surgery
- Surgical Oncology
- Trauma surgery
- Transplant surgery
- Vascular surgery
Wednesdays are academic days for students, which will include a Surgery Core Lecture Series to broaden students' understanding of the scope of surgical practice. Students will also participate in weekly skills labs. The suture and simulation lab will build needed skills to apply throughout this clerkship and during future rotations.
Our goal for students is to embrace surgery as exciting, interesting and challenging. We hope some students will pursue surgery as a career choice. However, all students will gain insight into the practice of surgery, which will aid in caring for patients in whatever medical field they do decide to pursue. We encourage students to be proactive learners, ask questions and involve themselves thoroughly in their education for the eight weeks.
Goals and Objectives
Grading and Evaluations
Surgical Textbooks and References
- Demonstrate knowledge and understanding of common surgical problems.
- Understand the indications for, and the limitations of, essential diagnostic studies used to evaluate patients with surgical problems.
- Demonstrate an understanding of surgical treatments, and alternatives to surgical treatment.
- To become familiar with various surgical procedures and know their expected outcomes and complications.
- Develop cost/risk/benefit appreciation as it applies to patient care
- Be familiar with action, dosage and use of common pharmacologic agents used in surgery (analgesics, antibiotics, anticoagulants, sedatives).
- Evaluate and assess patients with surgical diseases.
- Understand and possibly perform various basic procedures, such as:
- placement of intravenous catheter
- insertion of urethral (Foley) catheter
- insertion of nasogastric tube
- removal of surgical drains
- closure of surgical incisions
- removal of suture/staples
- dressing changes
- Understand how to and possibly apply specific protocol in the operating room (scrubbing, gowning, gloving, prepping and draping)
- Interpret common laboratory tests (CBC, electrolytes, blood gases, urinalysis, coags)
- Interpret common radiologic tests (CXR, KUB, UGI, BE, bone, nuclear tests, US, CT)
- Understand how to obtain and interpret EKG
- Acquire a caring and sympathetic attitude appropriate for dealing with patients with surgical illnesses.
- Acquire an appreciation for the collegial interaction necessary to work on the surgical service, in the OR, etc.
- Realize the scope of responsibility you assume as the surgeon and to that of the family and referring physicians
- Demonstrate an openness to recognize limitations by using resources referrals and consultation with supervising preceptors or others when appropriate
- Demonstrate an openness to receive constructive criticism
- Perform duties within a professional comportment encompassing such areas as attendance, dress code, and general demeanor
- Respect patient privacy information
For each presenting symptom, condition, or disease state, the student should be expected to know:
- Common associated symptoms
- Positive physical findings
- Differential diagnosis
- medical/surgical alternatives
- when treated medically, indications for surgical intervention
- risk factor assessment
- pre- and post-operative management
- complications: recognition and treatment
- Adjuvant therapies - indications and outcome
- Discharge: timing, patient education, follow-up, resumption of activities
SURGICAL ENTITIES TO RECOGNIZE:
In addition to the list of potential topics for Professor's hour, the student should be familiar with management plans for the following:
- Burn injuries
- Common anesthesia scenarios
- Common ENT problems
- Common orthopedic injuries and tumors
- Intracranial tumors/aneurysm/AVM
- Lung tumors
- Major milestones in surgical history
- Pediatric bowel disorders
- Prostate cancer/hypertrophy
- Renal calculi/masses/cancer
- Surgical ethics and end of life issues
- It is important to integrate into the surgical team. You are encouraged to follow individual patients throughout their hospital stay.
- It is appropriate to ask questions on rounds, in the OR, etc, regarding patient management.
- Be enthusiastic!
- Make an effort to be present in the operating room to see the induction of anesthesia, preoperative preparations, and the performance of surgical procedures.
- Volunteer to write history and physicals, brief op notes, post-op orders, progress notes, and to present patients on morning or afternoon rounds. It is appropriate to follow individual patients more closely than others.
Attendance is required at:
- Exams: mid-term, final SHELF, standardized patient exam
- Preceptor groups
- Professor's hour
- Respective general surgery service conference
- Skills laboratory
When not present at the above, your presence should be in:
- In-house consultation
- Non-general surgery service conferences
- Operating Room
- Outpatient Clinic
- Patient floor work
The lectures deal with both general surgery and subspecialty topics. Lectures are given at JHH on Wednesdays. Each night prior to the lecture, students should read about the topic for preparation of the day. In some cases, suggested reading is provided by the lecturer and can be found on Blackboard. If no reading is provided, students should refer to the Access Surgery website. The lecture time is a problem-based discussion on the topic. Handouts for some of the lectures are available on Blackboard.
WISE-MD ONLINE MODULES
Some of the lectures for this session have been replaced by on-line modules (Wise-MD). Students should register for Wise-MD access by visiting www.med-u.org and selecting "register" in the upper right hand corner. You'll need to register using ONLY your individual institutionally assigned email address (i.e. email@example.com). Once a student is registered, they may begin working on the modules. To access a module click on "WiseMD Surgical Modules", "Go to Modules" and select the appropriate one.
A list of the required modules is noted on the course schedule. Modules should take 20-45 minutes each, and can easily be completed during the Wednesday afternoon block of academic time. However, it is up to the students' discretion as to when they complete them as long as they are done by the given deadline for each grouping. The clerkship administrator will be tracking student progress for the required modules, and failure to complete these modules on time will result in deductions from their professionalism grade.
There are many additional modules available on the Wise-MD system that we encourage students to use as an educational resource and study aid.
PRECEPTORSHIPS (all students):
Each student is assigned to a small Preceptor group with whom he/she will meet once a week during the Surgical clerkship. The individual Preceptors will determine the structure of these sessions, but they are mainly to present common surgical issues in a problem based Socratic teaching format. This is a time for students to ask their Preceptor any specific questions they may have. These sessions are mandatory and are not graded.
SURGICAL GRAND ROUNDS (all students):
Surgical Grand Rounds are held in Zayed 2-119A from 7:30 a.m. to 8:30 a.m. each Thursday. Grand Rounds are an integral part of the surgical teaching program, and attendance is expected. Questions on Grand Rounds topics may be incorporated into the examinations at the end of the surgical clerkship.
SURGICAL SKILLS LAB (all students):
The skills lab is offered to all students as an opportunity to practice suture and knot-tying skills and to perform simple surgical procedures. This experience is directed by Drs. Michael Marohn and Stephen Yang, in the U.S. Surgical Minimally Invasive Surgery Training Center (MISTC) on Blalock 12 and held on Wednesday mornings 9:00 a.m. to 12:30 p.m. Students may opt in to participate in a live animal lab. The animal portion of the lab is COMPLETELY OPTIONAL and participation has no impact on the clerkship grade.
This is a one hour conference held at 8:00 a.m on Wednesdays in the MISTC conference room (Blalock 1220) for all students. Students are assigned the date of their presentation and in most cases, have been paired. Students are responsible for choosing a patient with a general surgical problem.
Students assigned as the presenter, are responsible for preparing a brief (10 minute) case presentation including pertinent history, physical examination, and workup with a historical perspective. Students whom are the discussant, must present a brief (10 minute) discussion of the pathophysiology and treatment options. However, both students are responsible for the presentation and should know each other's material.
The Professor will assign a grade based on the following components of each student's presentation. This will count for 2.5% of their total grade - all grades are final and there will be no challenges to this grade. Each of the following will be on a scale of 1 (worst) to 5 (best).
- Delivery: Is the student's voice clear and strong?
- Cogency: Was the information presented clearly?
- Organization: Was the topic presented in a logical interesting sequence?
- Length: Was the length of the presentation appropriate to the topic?
- Subject knowledge: Is there a clear grasp of the information and are questions answered correctly with elaborations?
- Preparation: Did the presentation evidence care in its preparation?
A letter grade is transmitted to the Registrar's office approximately 5 weeks after the clerkship has been completed. The grading system will be Honors, High Pass, Pass, Fail, and Incomplete. The cutoff score to obtain a final clerkship grade of Honors is 87%. If you fail the NBME, you will not be eligible for Honors as a final grade. To obtain a High Pass as a final clerkship grade, the cutoff is 82%. A score of 59% or below, will put you at risk of failing the entire clerkship.
The components of your final grade include:
- Clinical Score 60%
- General surgery rotation 50% (4 clinical evaluations)
- Subspecialty rotations 45% (1 clinical evaluation and case report per subspecialty rotation)
- Professionalism 5%
- Written SHELF Exam 25% ** MUST PASS
- Standardized patient exam 10%
- Professor's hour score 2.5%
- Mid-term written exam 2.5%
The written evaluations based on a student's clinical performance are filled out at the completion of each rotation by no more than a total of 4 (1 from faculty, 1 from chief resident/fellow and 2 from residents) evaluators of the general surgery service and 1 (faculty/fellow/chief resident) from each subspecialties. Scores are based on a scale of 1 (bad) to 5 (superior) on the following categories:
- Clinical knowledge
- Self Directed Learning
- Data Gathering (History/Interviewing)
- Physical Exams
- Problem Solving
- Clinical Judgement
- Integrity (not rated on evaluation)
- Response to feedback
- Communication with Patients
- Communication with Colleagues
- Oral Patient Presentation
- Clinical Data (Ability to record clinical data)
- Procedural and Technical Skills
SUBSPECIALTY SERVICE CASE REPORTS:
For each of your subspecialties, students are required to submit a 2-page case report on one patient that they have followed throughout their rotation as an inpatient, in the operating room or saw as a new patient in the clinic. A sample of case reports is located on Blackboard for review. These case reports will be given a grade of Fail (40%), Pass (60%), HP (80%), H (100%). These grades are considered final and cannot be challenged. The subspecialty grade will be based on this case report and one clinical evaluation.
Grade Appeals Policy: http://www.hopkinsmedicine.org/som/students/policies/grades.html
The NBME Shelf Exam is a 100 question multiple choice computer-based examination given to test the student's knowledge of surgical diseases and treatments. Questions on this examination are not based on specific individual lectures directly, but rather on topics within the broad field of general surgery and subspecialties. Students have two and a half hours to complete it. Students are required to pass this exam in order to pass the clerkship.
The mid-term exam is an on-line exam made up of 50 Shelf-like questions, covering lecture topics. Students have one hour and a half hour to complete it. The exam is placed on the Halsted site. The exam is able to be taken between 6:00 a.m. and 11:59 p.m. on the designated day.
The purpose of the SP examination is to evaluate your ability to gather clinical data and to diagnose clinical problems. These patient models will present common surgical issues that are covered during the surgical clerkship. This exam will consist of 2 patients and is scheduled at the end of the clerkship. Students will receive feedback after their performance by the SP. The grade on the SPE is weighted as 75% from the encounter and 25% from the student generated responses related to differential diagnosis and appropriate diagnostic studies. The exam is made available to view online and students will have 2 weeks from the day the exam is posted to review it.
Once the rotation evaluation is completed by a student, their clinical evaluations are available for review via E-Value to provide the student with constant feedback. Students will receive a packet half way through the rotation which will include logged hours, patient tracker and any scores that have been obtained to date. If a student would like to meet with the clerkship director directly, they may schedule an appointment through Trisha Arbella to do so. During this time, students may review any evaluation forms from the completed rotations and available grades from the mid-term exam and Professor's hour. This time will provide an opportunity to discuss any problems or issues, and advice regarding Surgery as a possible career option.
Students will be given a pocket sized booklet to have various surgical skills be observed and signed off by a resident or faculty. This booklet must be completed and submitted at the end of the clerkship. This ensures students will leave the clerkship with documentation that they have acquired these skills, and receive face to face feedback.
FEEDBACK TO STUDENTS:
Faculty and residents are encouraged to provide students with regular constructive feedback on their performance throughout the clerkship. As a means of facilitating this process, students are encouraged to regularly solicit feedback from their preceptors regarding their performance. Questions like "How did I do today" or "Is there anything specific that you've noticed that I could do better?" will help prompt supervising physicians and associated medical care staff to provide important constructive feedback. Students are provided a midterm feedback form which is used to solicit feedback from a faculty member of the student's choice (someone with whom they've worked with) .This must be signed after the feedback session has occurred and ensures students' receive face-to-face feedback at the midpoint.
STUDENT EVALUATION FORMS/WEBSITE (FEEDBACK FROM STUDENTS):
We have made an ongoing effort to evaluate the Core Surgical Clerkship over the years. We rely on evaluations from students' experiences during the Surgical Clerkship to help modify and improve the clerkship.
These evaluation forms will be available on line with E-Value. Students are asked to complete these final evaluation forms carefully, no later than 6:00 p.m. on the Wednesday afternoon during your intersession. Final grades will be reported as "Incomplete" if evaluations are not returned.
All evaluations are anonymous, so students are asked to be as honest and specific as possible (including names and particular issues). Service attendings will not see comments until all final grades have been submitted to the Registrar's Office, so student evaluations DO NOT affect the rotation grades.
CLERKSHIP ATTENDANCE POLICY: http://www.hopkinsmedicine.org/som/students/policies/BasicClrkshpAttendPolicy.pdf
As outlined in the Johns Hopkins School of Medicine policy, students are not allowed to miss more than 3 full days of responsibilities which are excused absences. Any days away from the clerkship must be documented and approved by the clerkship office. If students do not contact the course director in advance of any absences, they will be considered unexcused and will impact on the student's final grade and the final narrative to the Promotions Committee. All absences due to sickness, must be called into Trisha Arbella (410) 502-5062 or emailed the morning of the absence. Also, students are required to contact their team to let them know of the absence. All students who miss more than the allowed days above will be required to develop a plan for remediation of missed days with the clerkship director. Such remediation is a necessary requirement for successful graduation from the M.D. curriculum. Students are responsible for any lectures, teaching sessions, etc. which are missed during your time away. If a student is in need of a particular weekend off, they should arrange the schedule with their individual team. Students are expected to work 6 days per week, having Sundays off.
DUTY HOUR POLICY:
For the core clinical clerkships, required activities for students will be scheduled according to these guidelines:
- No more than 16 hours consecutive activities.
- A minimum of one day out of seven away from the Hospital, off duty.
- No more than 80 hours per week of required activities.
Clerkships will maintain a goal of 10 hour interval between daily required activities periods. In many instances, the 10 hour limit after evening call would limit the student's ability to present cases to the attending and impact grading and assessment. It is also recognized that students may opt to stay in the hospital for additional educational opportunities, such as discussions with house officers, observing a unique case, etc. Given the shortened duration of learning in the discipline that is available to students and the lack of direct patient care decision-making by students, the committee feels it is reasonable to suspend the "10-hour" rule when appropriate.
Taking overnight call is not a requirement of the clerkship. For students wishing to work a night float shift of 16 hours, we encourage students to obtain the Trauma pager from Zayed 6-107. It is best to schedule this shift when their team residents are on-call.
TRACKING YOUR WORK HOURS:
On a weekly basis, student work hours in the hospital must be recorded. The Clerkship Administrator will be tracking these hours and informing students by email and pager should we find a non-compliance with this policy. If a student is exceeding the work hours, appropriate steps will be taken with the services to ensure students can comply with the restrictions. The website for tracking hours is http://halstedsurgery.org/ .
Scrubwear is made available for "authorized users" in operating rooms, labor and delivery, cath lab, etc. Students are "authorized users" for their time on the Core Surgical Clerkship. The JHU I.D. badge will activate the autovalet system. Students must return one pair of scrubs in order to be dispensed another pair. Scrubwear may be worn in the hospital buildings, but must be covered by a tied cover gown or a buttoned white lab coat when outside of the Operating Room sterile areas. Students may not wear the scrubwear out of the hospital . . . for any reason! Security personnel will stop any individual entering or leaving the hospital in authorized scrubwear. Names of individuals not complying with the scrubwear regulations will be submitted to the Department Chair for action.
Appropriate professional attire must be worn during all clerkship activities. This includes
proper grooming, bathing and lack of distracting jewelry or body piercing. Lab coats must
be worn during all patient encounters. Scrubwear is not permitted during Professor's Hour. Inappropriate appearance will be reported to the Clerkship Director and to the Dean's office.
The following steps are to be followed when a student has experienced an exposure to blood or bloody/infected body fluids, a needle stick, cut or puncture wound, a mucous membrane splash, or a cutaneous exposure, especially if the skin is broken:
- Wash the exposed site immediately
- If needle stick, cut, puncture wound, or cutaneous exposure, wash with soap and water, alcohol, betadine or other cleansing agent
- If splash to eyes or mount, flush with clear water
- Inform supervisor or charge person as soon as possible with the incident
- Call 5-STIX immediately and report the incident. You may have to go to their office immediately. Remember to bring important patient information (name, number, DOB)
STUDENT MISCONDUCT POLICY: http://www.hopkinsmedicine.org/som/students/policies/relationships.html
- Essentials of General Surgery 4th edition; Peter F. Lawrence; Williams & Wilkens; 2006
- Essentials of Surgical Specialties 3rd edition; Peter F. Lawrence; Williams & Wilkens; 2007
- Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th edition; ed: Townsend; WB Saunders; 2008 A classic textbook. ***OUT OF PRINT***
- Brunicardi Schwartz's Principles of Surgery, 9th edition; ed.; McGraw-Hill; 2010
- Ed Doherty Current Surgical Diagnosis & Treatment 13th edition; Lange; 2006
- Current Surgical Therapy - 10th ed. J.L. Cameron; Harcourt 2011. A book dealing with up-to-date treatment of common surgical diseases.
- Cope's Early Diagnosis of the Acute Abdomen 22nd edition; W. Silen; Oxford; 2010. A classic book on the acute abdomen.
- Mont Reid Surgical Handbook 6th edition; ed. Stehr; Mosby; 2008.
- Abernathy's Surgical Secrets 6th edition; ed. A.H. Harken; Harcourt; 2009.
- General Surgery: Review. MA Makary, Ladner-Drysdale; 2nd edition; 2008.
This book can be purchased at a discounted rate to students by ordering on line at http://www.shelfexam.com/.
- Videos: HTTP://WWW.ACCESSSURGERY.COM
- Free Podcasts: HTTP:ITUNES.APPLE.COM/PODCAST/SURGERY-101/ID293184847
STUDENT RECOMMENDATIONS FOR NBME PREP:
- PESTANA - REVIEW NOTES. (Posted on Blackboard, under "Course Documents")
- NMS Casebook
- Pretest questions from www.nbme.org
- USMLE Question Bank