USMLE preparation and aiming for surgery residency: Facts, myths and a detailed strategy
Already a surgeon in home country: Do I still have a chance to become a surgeon in USA?
Most of the universities prefer recent graduates as their residents and the older graduate you are, there are less chances of you getting matched.
“This is a big fat lie in the field of surgery.”
I have been in touch with 26 people who got matched in surgery and according to this match experience, recent graduates are considered as burdens in the department of surgery. Most of the programs prefer home country surgery experience.
Places like Bronx Lebanon hospital in NY have residents who were surgery residents in their home country. In the field of surgery, if you have a post graduation degree from India, it’s a BIG plus in your resume. I have seen people who are done with their residency in India and with two years senior residentship experience in India, and 3 years of fellowship experience in USA getting matched into categorical surgery directly, in this match. So, old graduates only harm if you are not doing anything and sitting for preparing your steps. Surgery match has become very competitive these years and any form of home surgery experience makes you ahead of hundreds of applicants.
Aiming for surgery residency without any background surgical experience.
When I first started telling people that I want to go for surgery residency, people used to tell me that: why are you making your life miserable ? Surgery is not for IMGs, it is impossible to get surgery in USA, there is like 16% chance of getting matched in surgery for non american medical graduates (which includes US osteopath, US Caribbean graduates, US citizen who did medical school outside of USA and IMGs from all of over the world).
I kept reminding myself that I need one seat, one shot and I can be a part of that stats.
I am not denying this fact that getting any surgical field in USA in very difficult, but it is not impossible. When there is some thing hard to achieve, you need to work harder for that. The program directors in surgery residency programs need their residents to be determined and passionate for surgery and if they see that kind of determination in you, they will hire you. We are seen as very hard working and intelligent doctors in USA (thanks for our seniors who did commendable jobs so far). They don’t ignore this fact that we could be of their use, so WE HAVE A SHOT. I advise you, after being successfully getting matched in a surgery residency program of my choice, in 2015 NRMP match, do not listen to people who bring negativity in your life. I created a group of around 20 people on whatsapp, who had applied for surgery this year and 14 of them got matched. Each of them, were a potential surgery residency applicant, and they worked hard for it. In the end, they deserved it but the most important thing is that they were all foreign medical graduates, so if they can do it, you can as well.
Do note the best iOS app for USMLE preparation – Dailyrounds.
Getting most out of your surgery rotations: The Ideal strategy
After getting acceptance for electives, the real game starts, these 2-4 months of clinical rotations are going to decide where you are going to get residency or whether you are going to get residency at all or not. The acceptance letter will clearly mention the departments in which you are going to rotate.
Read about the preferred type of visa for surgery residency – USMLE surgery residency program: Why should you choose H1B over J1 visa?
Before going to USA
This is the time to gather all the information about the department of surgery of that hospital, which includes all the information about the names, research projects, positions, email addresses of the program director, chair, the faculty you are going to rotate with and other residents in surgery department of that hospital.
Besides this, it is very important to identify the research coordinator, elective coordinator and residency coordinator, these women will be helping you a lot in the long run, so learn their names, try to manage their contact information including email addresses and phone numbers, if possible add them on facebook.
Identify all the faculties you are going to rotate with and make your mind on the names of the faculty which you are going to target for your Letter of recommendation. Meanwhile, also learn about those subjects in which you are going to rotate, e.g., if you are going to rotate in transplant and trauma, then try to brush up all the basic knowledge about these subjects. If possible, buy some short books which you are going to read on your rotation from India itself. e.g., “SURGICAL RECALL” by Lorne H. Blackbourne (books are cheaper in India).
When you are there
The expectations from a medical student in a surgical team is being on time (it means before everyone else in the team), dress nicely, be professional, don’t make any blunder, be humble and polite. They are not going to expect you to do an appendectomy by yourself.
A typical day
Your day starts at 3:30am in the morning (if you take time to shower and bowel habits), the point is being in the hospital at 4:30 am, so better live right next to the hospital. The first thing in the morning that you do is, meet your fellow medical students who are going to rotate with you (you will be surprised that they will be in the hospital before you every single day no matter what). Every single day, one of the medical student is responsible for making the patient list, the earlier you will learn the electronic patient note software of your hospital (Cerner, Epic, Sunshine) better for you, it’s different for different hospitals. If you have a tablet/I pad with you, it’s a big plus because you can access all the patient list in your Ipad. You are supposed to print the patient list of your team and make a copy for every single member of your team, jot down the labs of every single patient in the list with a brief history, progress, assessment and plan and recent orders or change of medications. After making that list, you are supposed to go on pre rounds on the patients allocated to you before the residents come to the hospital. After taking a pre-round, jot down your notes which you made during your pre round including brief history and progress of the patient, overnight status, new chief complaint, your own assessment about the patient condition and your own plan for the patient.
Then the resident rounds (around 5:30 to 6:00am) will begin: You are required to have tape, scissors, suture removal kit, syringes, betadine, gauzes etc. in your pocket during the resident rounds, you are also supposed to present your own patients to the chief resident and note down the latest orders or change in plan made by chief resident in your notes.
There is a specific way of presenting patients in every surgical team, learn the patient presenting method of your team as early as possible then confidently present patients on rounds, your learning and analytical skills will be used here only.
After that, around 6:30-7:00am, the faculty round will begin, faculty rarely interacts with medical students during rounds but sometimes chief resident gives you the chance of presenting your patient directly to the patient so be ready for that golden opportunity.
After the faculty round, every one will be dismissed to do breakfast before finally gathering either in the operating room (OR) area or Clinics (depending on the day), I used to utilize that time to write the progress note of the patients in the computer and have it co-signed for my faculty so that they will have an idea that I saw that particular patient and I am following up on that patient every single day.This is the another opportunity to impress your faculty.
OR day
On the OR day, after your rounds, you will be heading to the OR area, you will be wearing scrubs today. The operations start around 7am every day and you can get a complete list of all the operations a day before electronically from that software of your hospital while at home, your duty will be to identify the faculty you are rotating with and see what cases he has for you. The next day, try to learn every single thing about that patient (from patient notes), about the anatomy of the procedure he is going to have (Zollinger atlas of surgical procedures), about the procedure the patient is going to have (Zollinger atlas of surgical procedures) and about that disease (Shwartz, Greenfield or Sabiston). If you do this much while you are in the OR, you will be ready to answer every single question that they may throw at you (which they rarely do), but you should be ready for that golden opportunity.
A day before your first OR day, you need to learn a lot about the scrubbing technique, gown and gloves wearing technique from Youtube. This is the moment when you could be totally embarrassed by nurses (trust me they will be waiting to yell at you for your first mistake), so be prepared.
Your first duty on your OR day is to learn about that patient from EHR (Electronic Health Record) and go to the patient bed really fast and stay there, wait for your resident to arrive who will take consent from the patient, then stay there with the patient and wait for your attending to come and talk to your patient, then again stay with the patient until anesthesia come, your job will be to take the patient to the OR along with anesthesia guys. After you enter the OR with you patient, introduce yourself to everyone, write your name on the board with M4 (Medical student 4th Year) in front of it and give your gown and two pairs of gloves with directions about which pair you wants to wear inside to the scrub nurse, be respectful to everyone as the atmosphere in the OR is pretty tense and chances of getting yelled at in the beginning are pretty high, after that ear eye protection (you will already be wearing cap and mark before entering the OR area). Do not touch anything unless you are asked to, your next job will be transferring the patient from his bed to the operating table, helping nurses and anesthesia, after the resident enters the room again, introduce yourself to him and help him in positioning the patient. Remember, never get scrubbed before your resident and attending, always scrub along with them, such that you won’t the first one in the room for the nurse to help wearing the gown and gloves, also don’t be too late such that the scrub nurse would be busy in helping the patient getting ready and you would be standing like a fool for your turn to wear your gown and gloves, don’t necessarily try to help when you are scrubbed in the beginning days, you will do more harm than help and your attending will get frustrated with you on your very first day. Your job would be to hold a retractor throughout the operation, meanwhile an attending could ask you an anatomy or procedure question in the middle so be ready for that (only if the case is going smoothly and attending is in a happy mood). Your entire focus should be on not doing any blunder and help when asked.
In the end of the case, your job would be to unscrub and help the patient getting cleaned, bringing the patient bed in the room, and helping the patient to be on the bed again and transferring it to the patient area. If you do this much without making any blunder (like itching my first day and I was yelled at by nurses and my faculty on my first case but by the end, I used to make the first cut for trocar placement and they used to make me dock the entire robot into the patient by myself, I did independent rigid and flexible cystoscopies. If you show patience, things will get better.
Clinic day
The clinic day also starts after the rounding, now instead of going to the OR area, you will head to the clinic, you will be wearing the formal dress on this day. The clinic area in US hospitals consists of common stations where doctors and nurses sit and work on the patient notes on a bunch of computers and several rooms in which patients would be waiting for doctors, there would also be a computer in a patient’s room just in case you need to show them their imaging or some lab results.
The moment you enter the station, you need to introduce yourself to everyone by your name and your position clearly, try to recognize your faculty and residents as quickly as you can by their names.
The patients get processed by the administrative staff in the front and they will be rushing in their allocated rooms, next a nurse would be taking their vitals and brief history, after the nurse will be done with the preliminary process, she will take the patient’s chart and put in a common shelf in the nursing station with a note on a white board with the patient’s last name and the room number in which the patient is. It means that the particular patient is ready to be seen.
Your job would be to ask your faculty if you can take that particular patient, depending if its an old patient or a fresh patient and on the complexity of the case, your faculty will either allow you or not. Once a case has been allocated to you, your job is to pick up the patient’s chart from that rack first, such that not more than one doctor will work on the same patient. Once you take a patient, that particular patient is your responsibility, no one else will see that patient. After picking up the chart, you need to pull information about that patient on the Electronic Health Record on the computer, read all the past visits of the patient, review all imaging, current medication, reason of visit, follow up appointment etc. After gathering all the information about the patient, head towards the patient area and knock on the door of the patient, enter in the room and introduce yourself (be confident) that “I am Dr. XXX working with Dr. XXX and I am going to take care of you today, How may I help you? “.
Your patient chart will be attached by a blank sheet where you should put your notes while interviewing the patient, after gathering all the information you need from the patient, do a final close up by saying “Thank you for your time, I will be back soon with Dr. XXX ” and leave the room. Finally come back to the station and wait to see when your faculty gets free, usually your faculty will sense that you are back and will ask you in his own “What have you got for me?”. This is the golden opportunity for you, this is the best time where you can show your potential, this is where you get to interact with you faculty the most, so if you are getting an option to go for OR or Clinics, don’t get fooled by the thrill of operating rooms, just go to the clinic and impress your faculty by your presentation skills and analytical skills.
Present your case to your faculty, your assessment of the patient and finally, what you will plan to do, this is a pre defined format of patient presentation and note writing also called as SOAP (Subjective, Objective, Assessment and Plan), after presenting the case to your faculty he will accompany you to the patient room and finally he will talk to the patient, take quick about all the major points during the interview, all the new points patient tells your faculty which he/she never mentioned to you (happens a lot), jot them down and the final thing what your faculty told to the patient. After coming back to the station, you need to write the note in the computer which will be co signed by your faculty later on, after reviewing your note. This is another golden opportunity where you can impress your mentor by your note writing skills, but this is double edged sword, there is a particular way of writing notes which your residents will teach you gradually but if your note sucks then it will be a burden on your faculty and he will probably never ask you to write a note for him again.
The key is that the faculty has an option to get a note from a resident or you, they always prefer resident’s note (less work for them), they give you a chance because they are very kind, but if you prove them that you are gonna be a burden on them, they will never ask you again, so practice on your note writing skills wisely.
There are few points you need to remember, never take a case which your residents wants to pick, don’t try to outshine yourself by putting someone else down, always be polite and as modest as you can with nurses, don’t be a gunner, give others chances (there will be third year medical students working with you as well), help them don’t be a burden, don’t take a case without permission, don’t try to occupy the computers in the station area in case your faculty/resident/nurse needs them, go to an empty patient room to use the computer there.
Other days
There will be other days which includes activities like:
• Grand rounds
• Morbidity and mortality rounds
• Tumor board meeting
• Pathology conference
• Radiology meeting
• Lecture series
• Quiz day/ jeopardy
• Skill training day
• Case presentation day
• Journal club day
Basically, you will go to all the places where residents AND medical students of that program are supposed to go, so make sure you know your schedule very well so that you can read about those things a day before and be ready for any questions rather than being a fool while looking at others.
The key point is to read, read and read, the more you will know the more you can tell. It will be hard but arrange at least 2-3 hours per day for reading, read in your free time in hospital, read on your way home while traveling, read while you can.
Also, make sure to volunteer, things will not knock on your door, you need to build opportunities some time for yourself.
Volunteering
• Ask them if you can present a case during the resident case presentation day
• Ask them If you can make a presentation on a topic to speak on journal club day
• If you are done with your clinics, then ask them if a case is going on in the OR area, rather than heading back home.
• Ask them if you can come on Saturday and sundays as well to help residents on call.
• Ask the residents if they can ping you if an emergency case comes in the night time.
• Ask them if you can write a case report of one of the interesting case you saw in the hospital
• Ask them if you can be a part of an ongoing study.
• Ask them if you can go out with residents during their weekend going out ritual (try connect with people, don’t be a nerd always).
In the end, I must say that during your rotation days, forget that you are in USA, stay in the hospital as much as you can, don’t think about where your other friends are going to out on weekends to see America. Trust me, you will have plenty of time to do these things later on in your life, these months are very crucial and utilize them well.
The best iOS app for USMLE preparation – Dailyrounds.
Six things you can do in college before USMLE step 1 preparation
USMLE WORLD: Ideal strategy and don’ts for your USMLE preparation
