Q&A took place on 8/8/2016 at the Cardiovascular Institute of Greater Los Angeles.
Q: What are some of the most common surgical diseases?
A:1.) Appendicitis, 2.) Cholecystitis, 3.) Diverticulitis
Q: How/when do you decide to surgically manage vs medically manage those surgical diseases?
A: As with all things it depends on the risks vs benefits, disease process, pathophysiology, patient symptoms, and patient willingness to undergo surgery. The general theme for the most common surgical cases (appendicitis, cholecystitis, diverticulitis) is to achieve source control. Source control is simply controlling the source of an infection. For example in appendicitis, the source of infection is an inflamed appendix. In this example we achieve source control by either cutting out the source (the appendix) or preventing spread of the infection by controlling with antibiotics. Now, deciding whether to use antibiotics or surgery depends on specific risks of the surgery. In the case of appendicitis, the vast majority of cases will be controlled by surgery due to the relative low surgical risks and good outcome with surgery. Contrast that with control of Diverticulitis: to treat diverticulitis with surgery requires a colostomy. The surgical risks are much higher, patient outcome and quality of life after colonostomy are not as favorable. Therefore a surgeon would be more inclined to manage diverticulitis with antibiotics rather than surgery. If however there are more confounding and emmergent factors, such as overwhelming sepsis, perforation, etc., then a surgeon would be more likely to operate to gain source control.
Q: What are some big surgical cases never to miss?
A: one of the biggest “don’t miss” surgical disease is Necrotizing Fasciitis. The most common infectious agents responsible for Nec Fasc are Strep, Staph, and Clost. Perfringes. Nec Fasc presents as an “underwhelming,” skin infection. The characteristic attributes are : 1. Rapidly progressing infection (within hours), 2. Surface skin is usually intact, erythematous, but symptoms are out of proportion to pain on exam, 3. there will be crepitus underneath the skin, 4. When the surface is pierced the underlying soft tissue will be necrotic with a milky white-chalk like appearance, 5. the patient’s lab results will return extremely elevated leukocytes with bandemia and hyponatremia. The treatment for Nec Fasc is rapid surgical debridement with wide margins. You just keep cutting away dead infected tissue until you reach healthy tissue. You know you’ve got healthy tissue if the tissue bleeds. After surgical debridement you aggressively treat with antibiotics to prevent reinfection. The antibiotics typically used are Vanco + sulfonamide + Zosin to get broad coverage.
Q: What are some qualities in a good surgeon?
A: Good surgeons stay calm in a crisis. Adaptability and making quick decisions based on reasoning is also important for surgeons. Some things that people don’t think about are also the determination and perseverance it takes to become a surgeon. Surgeons must be willing to accept failure and move on because sometimes patients will die and there is nothing anyone can do for them. A good surgeon will always think of those patients and wonder what else they could have done for the patient but ultimately will move on. Finally a good surgeon isn’t afraid to be wrong – just when you are wrong, make sure you don’t make the same mistake.
Q: How should I (medical student) study while on surgery rotations?
A: 1. Study your anatomy. Specifically study the anatomy relevant to the case you will be helping with. 2. Know the pathophysiology. You must know the diseases that caused the patient to need surgery and know what pathology can be controlled without Surgery. 3. Know how that case would present before requiring surgery. 4. Know differential diadnoses for that case. 5. Know how to work up the case you are assisting with.
Studying your patients and their disease will help you remember diseases better. Use Lawrence’s Essentials of surgery (https://www.amazon.com/Essentials-General-Surgery-Peter-Lawrence/dp/0781784956) as a primary resource on your rotation. Don’t study from Surgical Recall. You should use that book only as a quick resource.
A: What are some questions to ask at your residency interview?
Q: Always ask critical questions. The residency is trying to sell it’s program as much as you are trying to get in. Great questions to ask are, “What are the biggest weaknesses of this program?” “Why would I not want to come to this program?” “What did your last 5 chief residents end up doing after completing residency?”