The surgery clerkship is the entry point to a career in surgery. If you love working with your hands, thrive when handling a serious level of responsibility, and crave meaningful connections with patients (who have intense investment on both sides), you’re likely to do well during your general surgery rotation.
“I’m a surgeon. I like solving things.” – Atul Gawande
This comprehensive guide covers the surgery clerkship, including when to place this rotation, how to make the most of your rotation, surgery clerkship resources, the shelf exam, and the pros and cons of pursuing this specialty.
Intro to the General Surgery Clerkship
Clinical clerkships, also referred to as clinical rotations, give medical students the opportunity to practice medicine under the supervision of an established or practicing physician. They provide students with first-hand knowledge of what the wide variety of medical specialties are truly like on a day-to-day basis. Students can then use the knowledge and experience they gather during their rotations to make an informed decision about which medical specialty they’d like to pursue in their future medical career.
Most US medical schools require the following rotations:
Depending on your school, you may be required to fulfill other rotations, such as emergency medicine, radiology, anesthesiology, etc.
The general surgery clerkship is an entry point for students who want a career in surgery, and it also serves as a source of potential recommendations for future surgical away rotations you’ll need to take in order to advance on this career path. To all future surgeons: it is vital to treat this core rotation with consummate care and attention.
Typically, the general surgery clerkship is more heavily focused on skill acquisition as opposed to knowledge acquisition. Although the pathologies are domain-specific, your hands-on skills make or break your chance of becoming a surgeon.
If you’re not so keen on surgery, be sure to give it an honest try before dismissing it. However, if things still refuse to click after deliberate effort, don’t fret, and don’t push yourself. There are still the wards and the consults where you can practice clinical reasoning. Also, anesthetists are always open to teaching a new kid their craft.
When to Place the Surgery Rotation
Deciding on where to place the general surgery rotation depends on if you want to pursue it as a specialty. If you do want general surgery to be your specialty, it’s best to place it second or third out of the total of four quarters of the year. Do not place the surgery rotation at the end if you want to pursue it.
Doing so will ensure you have acquired a foundation of experience before entering the rotation you feel the most enthusiastic and passionate about. Placing it first, when you’re just getting used to your third year clerkships, will make it difficult for you to impress your seniors and attendings. Also, by not placing it last, you’re better able to collect the number of references you need to apply to away rotations and residency programs.
The general surgery rotation is filled with supportive staff and attendings, so it’s an ideal opportunity to work on any skills you want to continue to hone.
Keep in mind that you may not have the opportunity to choose your rotation order, depending on the rotation process of your school.
Making the Most of the Surgery Rotation
The general surgery rotation has two main components: the operating room and the wards and consults. The main focus of this clerkship is the OR.
General Surgery Services
During the first week, you will often begin with General Surgery services, which will ease your transition into the rotation. Here is what to expect.
You must wake up early to pre-round on patients. The best way to approach this is to start managing at least one patient in their postoperative period and two patients with scheduled surgeries in the upcoming week. This way, you can learn how to take care of patients both post-operatively and during their lead-up to the OR. This longitudinal approach teaches you how to treat a patient all the way from their preoperative visit to the clinic to their discharge.
While rounding, it’s important to take advantage of two opportunities. The first is gaining the trust of the attendings who manage your patients, which will unlock the ability to participate in their surgeries. The second, if surgery is a specialty interest, is to network with the attendings.
After testing your comprehension of the pathology on rounds, writing notes will help you consolidate the information. To fully understand the case, have two objectives in mind during this process. First, compare the case with other similar cases (pathology) and extract common findings as well as differences. Second, prioritize the steps that need to be taken next. For instance, a patient with chronic kidney disease will need urgent creatinine and BUN labs.
Lastly, check in on all of your post-operative patients and make sure they are comfortable.
Calls & Consults
One key component of calls and consults is finding an attending who is either a good mentor or someone who treats your pathology of interest. This will complement your general surgery services work. One day a week, or at a different cadence depending on your program, you will join the attending to assist with consults. The advantage is that you will have at least three procedures to select from when it’s time to go into the OR—your two patients from General Surgery Services or a patient you consulted on with your attending.
Consults also strengthen your knowledge for the boards in a straightforward way. You will practice the diagnostic and treatment algorithms demanded by the NBME on the shelf and Step 2 CK. Do you suspect adrenal adenoma with Conn syndrome? If so, order a CT scan and renin-to-aldosterone plasma ratio before jumping to the laparoscopic resection.
Trauma
Prepare for a hectic day when working in the trauma bay. Use the first shift to acclimate to the work and patient flow. Learning as much as you can about the environment and the healthcare personnel you’ll be working with will come in handy in the upcoming days. Taking the first day to note the variety of incoming conditions will provide a leg-up as you prepare for the cases.
Over the next few days at home, you can take the time to learn the bread and butter of trauma cases. Not only will the attendings be impressed with your knowledge, but by knowing how to act, you can provide actual utility to the medical team. In doing so, you’ll earn more responsibilities and brownie points from the attendings you decrease the workload for.
It’s important to be responsive, not reactive. The key to achieving success in the trauma bay is not only being resourceful in the OR, but also using your downtime for self-care. Cases are unpredictable, so once a case finishes, take care of your physical and mental health. Have a snack, use the bathroom, or meditate if you have the time. Meditation will help you build the mental clarity it takes to rapidly adapt to upcoming information regarding a patient.
OR
Operating room personnel need to see you have what it takes before they hand any responsibility to you, so it’s important to show them your skill during your first encounters. Always introduce yourself in the OR. The circulating nurse will be much happier when you do, and some will actively get annoyed if you don’t.
Remember that it is just as important to ask questions and be helpful as it is to complete tasks and advance your skill. Getting on the good side of the scrub tech/nurse and the OR team as a whole is a necessary ingredient in your recipe for success.
Demonstrate a good foundation by scrubbing in appropriately, knowing the case, and suturing when appropriate. This will highlight your interest to the attendings, which will result in good marks and even more responsibility. Observe the OR for at least 30 minutes in order to acquaint yourself with the medical team. The surgical game is frequently a team game; pay close attention to each of the surgery healthcare personnel to ensure your future interactions with them go smoothly.
On your first day in the OR, just observe; don’t try to do too much unless you’re asked to. Get a sense of the flow of things but it’s important that you stay out of the way, and don’t contaminate anything. Pay close attention so that you can determine where you will be most helpful based on your skill level, and then start taking initiative moving forward.
The OR game is a scaling process. While beginning with basic sutures at the skin level is a good starting point, try to do something different at least every other time you are in the OR. Was the previous suture a simple interrupted? If so, next time, try an intradermal suture. Consistently improving will enhance the attendings’ confidence in you. When they trust your abilities, they will give you more responsibilities in the OR.
When assisting the scrub techs, circulating nurses, and so on, don’t try to help move the patient, move the bed, prep the patient, and insert the foley all on the first day. If it is your first time in the OR, there is a good chance you could mess something up—and that will definitely leave a bad first impression. On the first day, simply observe. On the second day, start helping with one task, and then slowly scale up. You want to be the person people can depend on to do the task right.
During the day, don’t scrub into too many cases, as this can burn you out fast. While you need to acquire experience in order to build your future prowess as a surgeon, being part of three cases every four hours is not the way to build your skills. As a good rule of thumb, take a break whenever the case is unknown (with the exception of the trauma bay) or when there’s no idea on how to iterate differently on the next surgery.
Be mindful of your food and water intake. Don’t drink so much water that you need to urinate during a case, but don’t be dehydrated. If it’s hard to step away to eat, make sure to bring small snacks in case it’s a busy day.
The exact nature of your rotation will depend on how it is set up within your specific school. The exposures and settings you will experience will vary, as will the skills and knowledge you need to succeed. For example, you might not encounter any trauma cases during your rotation, and therefore not experience that type of fast-paced environment. How your rotation is designed will also play a role in your daily schedule, such as how early you need to come in, whether there are true dedicated OR days, etc.
Key Information for the Surgery Rotation
Trauma-related
The most common injury seen in the ED by general surgeons is blunt abdominal trauma from a motor vehicle accident (MVA). Common findings include the seatbelt sign, a distended abdomen, and multiple lacerations/abrasions. More serious findings may include peritonitis (rigidity, rebound tenderness, and diffuse abdominal pain), which could indicate a bowel perforation. This is a strong indication to emergently schedule an exploratory laparotomy.
This is the algorithm for blunt abdominal trauma:
- + peritonitis: exploratory laparotomy.
- – peritonitis.
A. Hemodynamically unstable patient
- FAST scan.
- If FAST scan is unavailable, use a diagnostic peritoneal lavage.
B. Hemodynamically stable patient
- CT scan of the abdomen.
Post-op conditions and pre-op contraindications
The most common postoperative complication is post-op fever. When the fever occurs indicates a certain etiology:
Day 1-3 (Wind)
- Pulmonary atelectasis, pneumonia.
- Prevent it with incentive spirometry and early mobilization.
- Treat pneumonia with antibiotics (4th gen. Cephalosporin + anaerobic coverage).
Day 3 and 4 (Water)
- Urinary tract infection (UTI) secondary to prolonged Foley catheter placement.
- Avoid by changing the Foley catheter frequently utilizing sterile procedures.
Day 4 and 5 (Walking)
- DVT and PE.
- Early mobilization prevents the formation of clots. Also, the patient should be anticoagulated (heparin) for the first few days. Compression socks are another preventive method.
> Day 7 (Wound)
- Surgical site infection.
- Proper wound care is preventive.
- Antibiotics are curative.
Knowing the labs, preoperative scores, and the consults a patient requires before an intervention is crucial to preparing your patient for the surgery. Your attendings will also appreciate (and ask you about) this.
- An anesthesia and cardiology consult is usually required before surgery.
- In the case of ordering labs, patients have the next indications:
- Hemoglobin: in patients who will undergo a surgery with predicted significant blood loss and in patients who are > 65 years old.
- White blood cell and platelet counts are not routinely recommended. However, an epidural or subdural anesthesia indicates that you should search for blood cell dyscrasias.
- Kidney function (i.e., creatinine) is screened in all patients > 50 years old with an intermediate or high-risk surgery, or in patients suspected of renal injury.
- Liver function tests (LFTs) are recommended only if the history reveals signs of hepatic injury, such as cirrhosis or hepatitis.
- Other indications for preoperative evaluation are:
- ECG if the patient has a history of arrhythmias, coronary artery disease, cerebrovascular disease, or structural heart disease.
- PFTs in patients with pulmonary disease (e.g., COPD or asthma).
- In regards to scores you can use:
- The preoperative mortality predictor score.
- Revised cardiac index for preoperative risk.
- Child-Pugh score.
- Oftentimes, a little medicine is tied within surgery, especially in critical care and burns. It is important to review electrolyte abnormalities and general hospitalist care, such as pain management, electrolyte abnormalities and repletion, diet orders, etc.
Here is a list of high-yield topics that are frequently tested on the shelf:
- Surgical indications for acute cholecystitis.
- Blowout fractures.
- Burns—management and the rule of 9’s.
- Causes of peritonitis.
- Abdominal aortic aneurysm.
- Ovarian torsion.
- Hernias.
- Biliary Colic, Cholecystitis, Choledocholithiasis, Cholangitis, Pancreatitis.
- Rhabdomyolysis.
- Shock.
- Compartment Syndrome.
Skill acquisition
Preparing the below essential skills before the clerkship will provide a huge advantage during the general surgery rotation. Although any field benefits from deep knowledge, learning these skills beforehand will encourage the attendings to give you more opportunities to enhance these and develop new skills.
- Knot tying and suturing.
- Scrubbing in.
- How to be helpful in the OR.
- How to present on rounds (surgery-style). Keep it short, concise, and to the point.
- Pre-rounding.
- Helping with tasks, such as wound care.
- Familiarize yourself with the surgical instruments.
- The most important skill to learn is to anticipate your team members. Understanding the steps of the surgery and the workflow of the OR will help you understand what should come next. Preparing what’s necessary for the next task beforehand will impress your residents and attendings, as it shows your efficiency and teamwork.
Sutures, knots, and scrubbing skills
Knot Tying
- Two-handed tie.
- Instrument tie.
- Bonus: one-handed tie. While this is impressive, it is better to have a solid and reliable two-handed tie than a one-handed tie. Most attendings and residents will ask you to do a two-handed tie.
- Practice knot tying, two-handed and one-handed. Practice using both your left and right hand.
- Practice knot tying with gloves and olive oil.
- Learn from our knot tying videos: How to Tie Surgical Knots.
Suturing
- Simple interrupted
- Simple continuous
- Deep dermal
- Running subcuticular
You could also learn horizontal mattresses and vertical mattresses for more surgical subspecialties, such as plastic surgery, but it’s not important for your general surgery clerkship.
There are three interrupted sutures every student needs to know:
- Simple interrupted suture
- Horizontal mattress
- Vertical mattress
Regarding scrubbing skills, the most important is the hand-washing techniques, the OR protocol, and dressing protocol. Here are a few notes on behavior etiquette in the OR:
- Keep your hands in your visual field the entire time to avoid contamination (use a prayer position).
- Avoiding contact between the front of your gown and the back of someone else’s gown (If they touch, the sterility of the gown is compromised).
- When facing the operating field, sneeze inside your mask. Don’t try to avoid it by facing laterally.
- When dressing up, remember inside-to-inside and outside-to-outside. For instance, do not touch the exterior of the surgical glove and the interior of the other glove in order to get it fitted right.
Surgery Clerkship Resources
The majority of students who have been through this clerkship believe Pestana’s Surgery Notes is the best review resource. It holds condensed material that will provide you with the knowledge required during consults and in the OR. The book complements the areas you might not understand from the UWorld explanations.
Another secondary resource for passive learning is OnlineMedEd. Their videos on pre-operative management simplify these algorithms.
UWorld is a great resource for both the shelf exam and the surgical component of Step 2 CK. Surgery is the second most important component of the Step 2 CK exam, amounting to 25-30% of the questions. All that to say, attention to the diagnostic and surgical treatments of various conditions is of the utmost importance.
On exam day, the surgical questions will include trauma-related algorithms, such as the one mentioned above, and preoperative or postoperative conditions.
Another great question bank resource is Amboss. The questions here work as a complementary resource, helping you with the harder topics at the end of the UWorld bank. It also improves your ability to deal with difficult questions on the real exam.
Use NBME forms to gauge your preparedness level before the shelf exam. This resource will help identify your knowledge gaps. Make sure you supplement your studying with enough UWorld questions before the NBME forms to ensure you do the best you can on them.
Lastly, before the shelf, make sure to review the more difficult topics. The easiest way to find your Achilles’ heel is by marking down the topics you struggled with in UWorld. Plus, it’s a good idea to take screenshots of the UWorld explanations of those topics so that you can create a rapid-review library. This will help compress and enhance your reviewing process when it’s time to prepare for the shelf exam.
Useful Apps for the Wards
MDCalc: Free app that allows you to calculate different risk/score calculations.
UpToDate: Find the most up-to-date information in medicine.
PreOpEval: An app to help you go through the pre-op process.
Zollinger’s Atlas of Surgery: A guide to each type of procedure that explains the steps of each surgical intervention in detail.
Surgery Shelf Exam
For the shelf exam, UWorld is more than sufficient. Before the exam, make a second pass through UWorld or see below. During the rotation, opt for two blocks of UWorld a day. To make things easier, go through the surgical questions only.
If you want to take things up a notch, start Amboss or Kaplan one month before the shelf. Amboss excels at providing you with really challenging questions that test your knowledge to the limits. On the other hand, Kaplan has a similar ambiguous question formulation that NBME has been targeting lately.
Lastly, it’s important to treat the shelf exam as the real Step 2 CK exam. This way, you can better accommodate the pre-exam jitters and identify your knowledge gaps before the real deal.
Note that depending on your school, the weight of shelf exams may vary. Your exams could be worth up to 80% of your clerkship grade, whereas other schools may only have a pass/fail process. Adjust the intensity of your studying to the weight of your shelf exams to make the most of your limited time.
Learn more from our How to Prepare for Shelf Exams Guide.
Residency Choices: Pursuing the General Surgery Specialty
Ranking just outside the top 10 on our MSI Specialty Competitive Index, the general surgery specialty provides access to an amazing variety of fellowship tracks. Once finished, you can go into:
- Colorectal surgery. It contains interventions such as hemorrhoidectomy and colorectal cancer excisions.
- Surgical oncology. Surgical oncology will invasively treat any type of tumor. Most often, they will be adrenal tumors or colorectal tumors, but they can also be thyroid tumors or pancreatic adenocarcinomas.
- Breast surgery. This specialty ****has surgeries like the lumpectomy, mastectomy, or breast augmentation implants.
- Cardiothoracic surgery. It includes ****surgeries such as coronary artery bypass grafts, lung tumor excisions, and valve replacements.
- Pediatric surgery. Pediatric surgery has the same pathology as general surgery but deals with children.
- Vascular surgery. You will perform the same interventions as the residents who chose a categorical vascular surgery track.
- Burns. The burns subspecialty is a tertiary care subspecialty, with the work being similar to that of a trauma surgeon. This means you will have a busy shift and blocks of time off.
- Hand surgery. Specialize in completing various surgical procedures on the hand. Hand surgeons can also be plastic surgery or orthopedic surgery trained.
- Plastic surgery. General surgery represents an easier way to get into plastic surgery in comparison with the categorical plastic surgery track.
The general surgery track lasts between four to five years, depending on the program you choose to pursue.
View our comprehensive Specialty Competitiveness Index, which assesses specialties based on USMLE Step 1, Step 2 CK, Top 40 NIH, publications, and more.
General surgery is the broadest of surgical fields, covering the surgical management of diseases from head to toe. If you like variety, then general surgery is the surgical specialty for you. The general surgery specialty allows you to be a generalist of the operating room, possessing the knowledge and skills for a wide range of surgical interventions. It might also serve as a stepping stone for you to get into the subspecialization you’re after.
Learn more about whether or not the general surgery specialty is right for you: So You Want to Be a General Surgeon (video and article).
Final Thoughts on the General Surgery Clerkship
General surgery is a core clerkship that provides you with the hands-on skills every doctor must have. Understanding how to perform knots and sutures is part of the daily practice of an EM physician and a primary care physician.
Creating and maintaining an aseptic field is extremely useful, such as when preparing blood cultures in the case of infectious disease physicians. Whether you are interested in pursuing a surgical specialty or not, remember that any physician benefits from having the dexterity of a surgeon.
General surgery is an amazing, often once in a lifetime opportunity, even for students interested in other medical specialties. Understanding preoperative contraindications will aid any cardiologist during a pre-op consult. Paying attention to how the anesthesiologist performs the intubation will create further opportunities for you to perform it as a future anesthetist.
Finally, the general surgery clerkship is the best entry point for future surgeons. It lays the foundation for achieving competency in any surgical field, such as neurosurgery, plastics, and orthopedics. Secondly, it’s a fantastic source of recommendations to help you secure a competitive surgical away rotation.
Whatever your comfort or interest level, it’s important to stay open-minded and curious about the range of different experiences and challenges general surgery will throw at you. You may discover a new set of skills you never knew existed.
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