Hurricane Jill

ASBITE

I don’t know what to make of that test. Halfway through, I was wishing I had busted out Costanzo’s BRS Physiology to study, instead of all those stupid ABSITE review books. Seriously.

And because I’m one of those people, I checked my answers afterward. And either they were wrong in sneaky ways, or I actually got some questions right. Plus it seemed to me like the whole test was basically the same 50 questions, asked 5 different ways.

Or maybe I just totally failed it.

A tiny bit of mentoring

Today I actually learned something that will be useful to me. Well, OK, it was yesterday. But I was on call last night, so it still feels like it was today.

When you’re an undesignated prelim in general surgery, attendings make two basic assumptions about you. First is that you want to be a general surgeon as your primary or at least your backup choice, and second is that you failed to match in general surgery (i.e. you must have had a serious deficiency in your record). Neither of those things is true about me. But I recognize that people tend to see what they expect to see, and a prelim intern is assumed incompetent until proven otherwise. If you want to change their opinion you have to work twice as hard as the guy who got a spot and thus is assumed to be competent.

But I knew that already, and that’s not what I learned yesterday.

Another hazard of the job is that attendings constantly forget that I’m not trying to become a general surgeon, and occasionally (OK, frequently) lecture me on what I will need to know and the skills I need to develop for that field. For example I’m constantly told that I need to be more proficient at two-handed knot tying. I’ve consulted with some of the neurosurgery designated prelims, and they get the same criticism, despite the fact that none of us have EVER seen a neurosurgeon do a two-handed tie. I’ve seen most general surgeons use them, and most plastic surgeons, but the neurosurgeons? Never. Not once, at any of the seven programs where I’ve spent time in the OR. In fact, the only time it’s ever come up was back in third year when I was having problems getting my one-handed ties tight enough to close galea, and had to demonstrate (later, outside the OR) that I could do a two-handed tie without difficulty. I believe I asked at that point whether there was any situation in neurosurgery where I would actually use a two-handed tie, and was told no, that it was just a building block.

But that’s also not what I learned.

So yesterday we had a consult on a neck mass, which resulted in a massive pimp session on the differential diagnosis of neck masses. I kept giving specific diagnoses that were based on the patient’s presentation, and the attending kept saying, “No no no, you need to do it systematically. This is why people fail their oral boards – they don’t go through the differential systematically.” I complained that it seemed dumb to list a bunch of diagnoses that aren’t even a realistic possibility for this particular patient. And he said, “I know it seems silly, but you have get over that. The examiner has a list of items he wants to hear you mention, and your goal is either to mention all of those items, or to demonstrate such knowledge of the subject that the examiner will stop you before you finish and check them all off just to move the test along.”

So he explained how he would answer a question like that. He said he would start with categories: congenital vs acquired, and then break them down into subcategories: infectious, inflammatory, neoplastic, etc., and then begin listing specific diagnoses and commenting on whether they were realistic for this particular patient. While he was talking, I had a flashback to one of my Clinical Diagnosis group’s first meetings with our preceptor (who was at that time the chief resident in medicine, and is now finishing his fellowship in nephrology). We were seeing a patient in the Charity ER with probable secondary syphilis on top of SLE and a number of other unfortunate medical problems (i.e. an extremely complicated patient), and he was explaining the way to approach an undiagnosed new problem. I remember very vividly him going through the possible explanations in almost exactly the same way: infectious, inflammatory, metabolic, neoplastic, etc.

And the light went on inside my head. So that’s what people mean by differential diagnosis. Nobody ever really explained it, and for some reason I thought it was just his particular way of approaching a problem, and specific to internal medicine.

The method of diagnosis that we were explicitly taught totally skipped that step. And intellectually I felt its absence, but I had a broad enough knowledge of the diagnostic subcategories in medicine to obscure its effect. Not so in surgery. Or at least, my knowledge is not already organized like that, as it is in medicine. So I need that step for the diagnosis of surgical problems.

And that’s how you pass the oral boards. It’s the same thought process as medicine, just applied to surgical topics. And done inside the head rather than in endless discussions on rounds. As much as we talk about the huge gulf between surgery and medicine, the difference is just in the application. We have different solutions to the problem, but the approach to diagnosing it is essentially the same.

So the attending who was grilling me went on to say that even the dumbest surgeon can pass the oral boards by using this kind of systematic approach, and some of the smartest ones have failed it by neglecting to do so.

Wow, talk about useful advice! Even though it was totally in the context of the general surgery oral boards, I’d be willing to bet that the neurosurgery oral boards are no different in this respect. Just different topics. So I’m definitely going to start approaching topics in that manner, both in surgery and neurosurgery, because in addition to helping with the boards, I think it will make me a better surgeon all around. I already do it to some extent for neurosurgical problems, but I think it will also make me better at general surgery for the few months I have left as an intern.

Although it won’t help me with the ABSITE two weeks from now. Ugh!

Not in Kansas anymore

I’m over at Children’s now. After a very pissed-off signout from last month’s intern (though he wasn’t pissed off at me), I was expecting a horrible beat down this morning on rounds. But it didn’t happen, thanks in part to that very signout, and the fact that my own inpatient peds experience was pretty solid. Peds surgery is a little different, in that it involves all the bowel crap I hate from general surgery combined with the vitals that would be scary in adults, diets in kcals and urine in ml/kg/hr I recall so fondly from peds. Not to mention the little munchkin patients and their wacky genetic syndromes and birth defects etc. Plus there’s surgery, so there’s the potential for this to be really enjoyable. I’m curious which way the balance will tip this month. Will I love it? Will I hate it? Will I be somewhere in the middle? I don’t know.

What I do know is that no matter how much I love it, I am not going to do a general surgery residency just so I can do a fellowship in peds surg. Nor do I want to go into peds, minus the surgery part.

We’ll just have to see what happens.

Cancerous

Newsflash: constantly busting my chops no matter what I do does NOT make me try harder. It makes me want to STOP trying altogether.