40th Anniversary
1972-2012
August 2012 • Volume 39 • Number 8
The Independent Monthly Newspaper for the General Surgeon
Opinion
101 Tips for
Surgical Internship
B Y M ARC A. N EFF , MD
Just over 10 years ago, I grad-
uated from surgical residency.
Since that time, I’ve accumu-
lated many gray hairs from an
unimaginable variety of patients
and surgical pathology. Recently,
I began the painful process of throwing
out some of my study materials left over
from that indentured servitude, and, in a
Pick and choose your
battles wisely—your
reputation and mental
health depend on it.
box of my old antiquities, I came across
a remarkable treasure—my hospital’s
“Tips for Surgical Internship.” I spent
hours crafting this project with two of
my fellow surgical interns. The com-
position amassed the wealth and depth
of our knowledge approximately two-
thirds of the way through our internship.
Looking at this list now, I’m impressed
at how wise I was when I was so young
and innocent. I once heard it said that
with “wisdom comes bad experience,
and that it is best to learn from someone
else’s bad experience, than your own.” It
see TIPS FOR INTERNSHIP page 23
Principles and Practice of Surgery:
With STUDENT CONSULT Online
By O. James Garden
see page 27
General Surgery Newss is pleased to introduce the work of Chad Hoover. Above is his
Ephemera #5,, 48” x 48,” oil on canvas. In his paintings, Mr. Hoover presents the view-
er with a surgeon’s point of view. For further description of his work, see page 24.
Surgeons More Comfortable
Applying Z0011 Data,
Sentinel Lymph Node Biopsy
B Y M ONICA S MITH
PHOENIX X—After results of the Amer- American Society of Breast Surgeons
ican College of Surgeons Oncology shows that surgeons at one large insti-
Group’s ACOSOG Z0011 trial were tution have grown increasingly com-
released—first the local recurrence fortable applying the Z0011 data to
data in 2010 ((JAMA A 2011;305:569- their patients.
575) and then the survival data in In August 2010, the University of
April 2011 at a meeting of the Ameri- Texas MD Anderson Cancer Center,
can Surgical Association—it has been in Houston, assembled a multidisci-
unclear how the trial’s findings have plinary team of surgeons, radiation
influenced practice. Research pre- oncologists, pathologists and medical
sented at the annual meeting of the see AXILLARY LYMPH NODE page 20
INSIDE
In the News
Cheap, Effective Solutions
in Trauma Care Are Born
in Africa. ............................ 8
GENERALSURGERYNEWS.COM
®
Ventral Hernia
Repairs a Financial
Bust for Hospitals?
Money Lost on Most
Procedures at One Facility
B Y C HRISTINA F RANGOU
SAN DIEGO—Ventral hernia repairs are
one of the most common surgical pro-
cedures in the United States. But for
the hospital’s ledger book, these proce-
dures add up to a financial loss.
Ventral hernia repair, particular-
ly biologic mesh repair, results in
overall financial losses for the hospi-
tal, according to a new study present-
ed at the 53rd Annual Meeting of the
Society for Surgery of the Alimenta-
ry Tract, a part of Digestive Disease
Week 2012. Inpatient synthetic mesh
repairs were associated with a net prof-
it of $60, meaning they were “essential-
ly budget neutral” for the hospital. All
other ventral hernia repairs were asso-
ciated with net losses, maxing out at a
loss of $8,370 per procedure for biolog-
ic mesh repair.
“At our facility, the vast majority of
open ventral hernia repairs were per-
formed at a financial loss for the hos-
pital,” said lead investigator Drew
Reynolds, MD, instructor of surgery
and minimally invasive surgery fellow,
University of Kentucky, Lexington.
The study did not take into account
readmissions, which would have fur-
ther added to the losses, said experts.
“Dr. Reynolds and his colleagues
have presented a disturbing financial
profile for ventral hernia repair, which
would in fact become even more grim
if the cost of readmissions were added,”
see VENTRAL HERNIA REPAIR page 6
Opinion Surgeons’ Lounge
The FBI and Health Care A patient with
Fraud: Tracking a espohageal diverticula
Dishonest Few ............... 12 and a leiomyoma .............. 16
GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 201 2 Opinion 23

Don’t get cocky until

TIPS FOR INTERNSHIP
in addition to whatever other read- through the night
continued from page 1
ing you have to do to care for your you have completed 31. Never let them see you sweat
patients 32. Your program director’s word should
24. Take one night completely off each your residency … be regarded as law
is to that end that I share with you now week somebody always 33. Never turn down an invitation from
the pearls from that time. 25 . Don’t wait until the night before an attending for dinner or a research
to do any presentations, and always knows or has seen more project
Tips for Surgical Internship practice 34. Be eager and ask questions in the OR
1. First do no harm (Primum non nocere) 26. Exercise at least three times a week department (ED), patients going to and on rounds. It lets the attending
2. The chief is always right 27 . Fresh fruit and vitamins never hurt a the OR or crashing patients when know that you are interested and
3. Your residency is like a family … surgical resident on call (even surgical subspecialty thinking
never dishonor the family 28. Sign out difficult patients to residents patients) 35 . Don’t order a test unless it is abso-
4. Always do your best on call 30. See your patients twice a day to lutely necessary and be ready to jus-
5. Resident safety before patient safety 29. Always inform the chief-in-house see what consults have been writ- tify ordering it—they are often costly
before patient comfort about patients seen in the emergency ten, and be sure that they will live see TIPS FOR INTERNSHIP page 24
6. Call for backup
7. Shield your attending and your chiefs
from extra work but keep them
informed
8. There is no completely benign inter-
vention (even a nasogastric tubee can
kill)
9. Not every patient needs an opera-
tion before they die (credit … Alfred
Blaylock)
10. Be honest with yourself: Do not

11.
attempt solo tasks above your ability
Check the operating room (OR)
surgeon preferred anatomical coverage and conformance…
schedule before leaving the hospital
each day
12. Read about cases night before day
in OR in Surgical Atlas and Surgi-
cal Text
13. Notify upper-level residents about
complex cases and they will return
the favor regarding simpler ones
14. Speak up when you don’t know
something or you may hurt someone
when you intended to help
15 . Always remember that you are on
the same side as the nurses, respirato-
ry therapists … and treat them with
the same amount of respect that you
expect
16. Eat when you can, go to the bath-
room when you can, sleep when you
can, read when you can and always
a new dimension in laparoscopic hernia repair.
call your significant other when on
call
17 . Call the cafeteria to set food aside
if you are running late—-don’t let
your patients suffer because of your
appetite
18. Write all your notes in the morn-
ing before you go to the OR or a.m.
conferences
19. Everyone should have an assessment
and plan in legible handwriting
20. Memorize the beeper numbers of
the surgical residents and the phone
numbers for each surgical floor
21. Be kind to the medicine and fami-
ly practice interns because they will
refer you cases and be a source of
information for you about cases that
encompass their specialty
22. Pick and choose your battles wise-
Find out more about Atrium’s C-QUR CentriFX™ hernia repair solutions at the
ly—your reputation and mental
health depend on it 2012 ACS Annual Clinical Congress, Chicago, IL, Booth #1628
23. Read an hour of general surgery a day
© Atrium Medical Corporation 2012. All rights reserved. Atrium and C-QUR CentriFX are trademarks of Atrium Medical Corporation, a MAQUET GETINGE GROUP company.
24 Opinion GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / AUGUST 2012

TIPS F OR INTERNSHIPS
66. Don’t put off to tomorrow what you can do
today because tomorrow can always be worse
continued from page 23
67. It is more work to avoid work than to just do it
and get it over with
and uncomfortable for sick patients (the Pandelid- 68. Call in all of your own consults and your con-
is Principle). sultants will know what you are consulting Never tell one
36. Surgery is not a spectator sport—you sometimes them for
need to be aggressive and ask to do things 69. Labs and diagnostic tests are never a substitute
attending, “This is
37. Doctor means teacher so don’t pass up an opportu- for a complete history and physical not how Dr. ___
nity to teach a medical student, nurse or other health 70. It is not so important which book you buy, as
care provider because it will earn you their respect it is to read the books you have already bought
does it.”
and confidence 71. An acute abdomen does not always equal an
38. Being tired is not an excuse for being cranky operation
39. Medical students deserve your attention in return 72 . Even Cope’s Early Diagnosis of the Acute Abdomen 89. Always show the films to a radiologist. Your attend-
for their hard work believes that surgical patients merit appropriate ing will ask you to and the radiologist will teach you
40. Don’t make a mess of your on-call quarters or lounge analgesia after evaluation by a surgeon something
because you will make an enemy of your roommate 73. Wash your hands between patients unless you enjoy 90. Starting off sentences with, “Do you have a moment?”
and housekeeping putting your patients on methicillin-resistant Staph- will win you more friends with nurses and attending
41. Leaving notes on problem patients on call is a way ylococcus aureus and vancomycin-resistant entero- than simply interrupting what they are doing
of letting people know where you were and what you coccus/enterococci contact precautions 91. If you develop any conflicts, discuss them privately
were thinking 74. Not putting a blue pad on the patient’s bed before a 92 . Bringing food to nursing floors on call is similar to
42 . Anticipating the complications of any procedure procedure is a great way to make an enemy of a nurse bringing a peace offering and will help make your
you do will help you identify problems when they 75. If your attending has to write orders or add more night more pleasant
happen than his signature to your note, you are not being 93. Learn the nurses' names ASAP
43. Respect your patients’ privacy and feelings—let complete enough 94. Always try to educate your patients about their dis-
them pull up their own gowns, don’t rip off ban- 76. Getting up and rounding early will give you the ease so that they can make informed decisions
dages, apologize when appropriate and pull curtains time you need for unexpected problems and to eat 95. There are those who are great surgeons only in the
shut before examinations breakfast OR and there are those who are great surgeons even
44. Don’t go out drinking pre-call 77. It is a bad career move to embarrass a colleague or outside of the OR … you can learn from both
45. On days when you aren’t going to the OR, dress like attending at a lecture unless you are ready to go into 96. Don’t get cocky until you have completed your resi-
a doctor private practice dency … somebody always knows or has seen more
46. Keep a clean shirt/pants/blouse/underwear in your 78. Don’t forget your hobbies because they will help 97. A practical joke once in a while will keep you and
call room keep you sane your colleagues sane. You should enjoy your chosen
47. Only keep in your pockets what you absolutely need 79. Not writing discharge instructions legibly is a great profession
48. Be regular about cleaning your apartment, paying way to ensure that your patient will contact you 98. Be careful what you say and address your colleagues
your bills, doing laundry, checking mailboxes and immediately after discharge as “Doctor…” over voice pagers and in front of
completing charts in medical records 80. Before acting on a critical lab value or vital sign, think patients
49. Being a surgeon means being an internist who can about whether it needs to be repeated or confirmed 99. Every attending has their own little quirks—-keep
operate 81. Know everything about appendectomies; they are track of them
50. Clinic is not a chore—it is the closest thing to a res- likely to be the first case you will get to do 100. Never tell one attending, “This is not how Dr. ___
ident’s own office 82 . Unless you like being awakened repeatedly through- does it.”
51. Arrive early to the OR, read the chart and prep out the night, make sure your post-op orders include 101. Your reputation will form by the end of the first
the patient whenever possible on general surgery orders for pain, nausea, fever and diet week, people will recognize you by the end of the
procedures 83. Avoid abandoning your attending and call team first month, so be extra vigilant in the beginning
52 . Be prompt to lectures and meetings when your attending’s cases run past 5 p.m.
53. It is wise to keep some deodorant in your surgical 84. Check out the other surgical clinics like ortho or If you follow even half of these as you move through
locker plastics to find easy cases that you may otherwise your surgical residency, you will be well ahead of the
54. Don’t bring your beeper into the OR unless cleared not be exposed to curve. A heartfelt and special thanks go to my fel-
with the attending surgeon 85. The earlier you arrive, the emptier the parking lot low interns, Nick Cottrell and Sridhar Chalasani, who
55. Always carry an extra beeper battery with you 86. Don’t be afraid to call the attending but don’t call helped me with this comprehensive list and helped me
56. Don’t change the schedule without the permission until you get your sh_t together survive that grueling year.
of the chief of the day 87. They’re really not yourr patients; this is why you
57. Sign up for vacations early sometimes/frequently get overruled —Dr. Nefff is medical director of the Kennedy
—
58. Simple audiovisuals help with complex morbidity 88. Never leave the hospital without checking all the University Hospital Bariatric Surgery Program,
and mortality presentations labs and x-rays you have ordered Cherry Hill, N.J.
59. Swallowing your pride, and not burping, is part of
being an intern
60. Try to read the abstracts from a surgical/medical
journal whenever possible
Ephemera # 5
61. Don’t dump on your colleagues because revenge is Chad Hoover, 48” x 48”, oil on canvas
sweet The Ephemera Series comments on humankind’s
62 . Don’t fall behind on your OR logs or you will never struggle against mortality. Becoming more than a
catch up record of history, Hoover’s work places the viewer into
63. Teaching yourself and your peers is part of adult the visual vantage point of a surgeon. The anonymous
learning identity of the patient, the surgeon, and assistants
64. No matter how bad things get, remember that you invites the viewer to participate in roleplay, where they
have the one thing your sick patients don’t have, your are directly confronted with the borderline of life. In
health the coming months, General Surgery News will feature
65. Treat all patients as if they were your mother, father, Mr. Hoovers work from the Ephemera Series.
sister, brother or child, and you will never go wrong