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Advice to a resident: A surgeon's notebook
Journal of Pediatric Surgery APRIL 1990
VOL 25, NO 4
EDITORIAL:
Advice to a Resident: A Surgeon’s Notebook By Michael R. Harrison and N. San Francisco,
TO OUR RESIDENTS: Surgical training is largely a self-educating process. In learning and continually refining your craft, an enormous amount of information must be assimilated. To be useful, the information must be organized and categorized. Information derived from reading journals and texts, and from attending lectures, courses, and conferences is best collated in a well thought-out file system. But the multitude of fine technical points involved in the actual conduct of an operation are more difficult to organize. Learning to perform operations well is difficult for a variety of reasons. First, there are many fine points involved in each step of a multitude of different operations. Second, the multiple tricks in the armamentarium of the master surgeon are usually imparted only across the operating room table, where notes and sometimes even words are extraneous; many of the subtle points are recognized only by the perceptive and attentive observer. Third, surgical technique is often considered a simple manual skill unsuitable for intellectual analysis and refinement. It is not obvious to the novice that in the performance of technical maneuvers, there are usually several ways to perform even the simplest step. Finally, surgical training is so long and varied that the variety of techniques used for common bile duct exploration that seemed so obvious when participating in three cases per week on a busy general surgery service may be extremely difficult to remember after several months on cardiac surgery, gynecology, and anesthesia rotations. The fine technical points involved in the less frequently performed operations are usually completely lost. The question is how to organize and categorize technical details. Dictated operative notes are not satisfactory because they are too wordy and cumbersome to be used as a reference and are seldom filed by category of operation. A surgical atlas is an excellent Journalof Pediatric
Surgery, Vol 25, No 4 (April). 1990: pp 379-380
Scott Adzick
California
technical guide, but is not useful for recording the many technical tricks learned from different surgeons throughout surgical training. This difficulty might be overcome by a sparsely written atlas with simple line drawings to which notes and drawings can be added. A simple but seldom used solution is to write technical notes to yourself. This should not be a big deal-a simple loose leaf notebook kept in your surgical locker will serve this purpose. One page is devoted to each operation or topic (eg, fundoplication, bowel anastomosis). A brief outline for each operation would include (1) preoperation: notes on surgical indications, special preparations, bowel preparation, drugs, tubes, etc; (2) exposure: notes on the position of the patient, prepping and draping, position of the surgeon, assistants, and scrub nurse, the incision, types and position of retractors for exposure, etc; this overview is perhaps the most useful means for dissecting and analyzing an operation; (3) the operation in sequential steps: notes on the technical maneuvers written in schematic outline-it is helpful to divide complex operations into clearly defined steps with alternative approaches for each, drawings are helpful; and (4) closure and postoperative care: notes on tube and drain placement and special postoperative considerations such as when to discontinue antibiotics, remove drains, etc. These notes should be cryptic, jotted down in telegraphic style, and embellished with drawings and doodling. Complete sentences are disallowed, and the notes need not be intelligible to any other person. But the key to the surgeon’s notebook as a learning device is
From the Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, CA. Address reprint requests to Michael R. Harrison, MD. FACS. Department of Surgery, University of California, San Francisco, 3rd & Parnassus Aves. HSE-585, San Francisco, CA 94143-0510. o 1990 by W.B. Saunders Company. 0022-3468/90/2504-0021$03.00/0
379
380
discipline. Notes are made immediately after an operation, as automatically as dictating an operative note or changing out of your scrub suit. When an operation is first recorded, it may take 10 to 20 minutes to rethink the various steps and details and organize them in your notes. This is an extremely useful learning device in itself, since this will fix the operative steps in your mind and you will learn as much from one operation as 10 otherwise. However, the major advantage of this system is the ability to accumulate multiple details and multiple alternatives for each step of each operation, gleaned from years of training at different levels with different attending surgeons in different hospitals. It now becomes easy to note on the same page variations in technique, the advantages and disadvantages of alternative maneuvers, and finally, with experience, your own preference. The surgeon whose armamentarium includes a variety of techniques will have patients with fewer complications than the surgeon whose repertoire is limited to one way of dealing with a problem. This little notebook now becomes an extremely efficient way to accumulate a mass of small pieces of information and bring them all to bear on one particular step of one particular operation. As you progress during residency and begin to perform operations with less supervision, you should frequently review and embellish your notes. It takes only a few minutes while changing into scrub clothes to brush up on the details
HARRISON AND ADZICK
of the different steps of a complex operation that is infrequently performed. This permits mental rehearsal before the operation that will be the actual demonstration. You will soon be improving and synthesizing the various maneuvers you have learned. Your notebook will prove useful even in this period of consolidation. This learning system should not become a burden. It requires some discipline and only a few minutes of time to record the small technical details learned in the operating room. When nothing new is learned, nothing need be recorded. But, when small tricks are recalled and recorded, your appreciation of the surgical craft is enhanced. Operations are no longer a blur of retractors, tissues, and sutures, but a symphony of small precise steps that can be delineated, recorded, and assimilated into a masterful operation that is a technical joy. Some gifted residents may not need such a mechanism to help them remember and master the many technical nuances they are exposed to during the hundreds of operations performed during 5 to 10 years of residency. But most will find it useful. They will follow the example of such technical masters as Leonardo da Vinci and Harvey Cushing and keep a little notebook for themselves. Sincerely,
Your Fellow Surgeon
VOL 25, NO 4
EDITORIAL:
Advice to a Resident: A Surgeon’s Notebook By Michael R. Harrison and N. San Francisco,
TO OUR RESIDENTS: Surgical training is largely a self-educating process. In learning and continually refining your craft, an enormous amount of information must be assimilated. To be useful, the information must be organized and categorized. Information derived from reading journals and texts, and from attending lectures, courses, and conferences is best collated in a well thought-out file system. But the multitude of fine technical points involved in the actual conduct of an operation are more difficult to organize. Learning to perform operations well is difficult for a variety of reasons. First, there are many fine points involved in each step of a multitude of different operations. Second, the multiple tricks in the armamentarium of the master surgeon are usually imparted only across the operating room table, where notes and sometimes even words are extraneous; many of the subtle points are recognized only by the perceptive and attentive observer. Third, surgical technique is often considered a simple manual skill unsuitable for intellectual analysis and refinement. It is not obvious to the novice that in the performance of technical maneuvers, there are usually several ways to perform even the simplest step. Finally, surgical training is so long and varied that the variety of techniques used for common bile duct exploration that seemed so obvious when participating in three cases per week on a busy general surgery service may be extremely difficult to remember after several months on cardiac surgery, gynecology, and anesthesia rotations. The fine technical points involved in the less frequently performed operations are usually completely lost. The question is how to organize and categorize technical details. Dictated operative notes are not satisfactory because they are too wordy and cumbersome to be used as a reference and are seldom filed by category of operation. A surgical atlas is an excellent Journalof Pediatric
Surgery, Vol 25, No 4 (April). 1990: pp 379-380
Scott Adzick
California
technical guide, but is not useful for recording the many technical tricks learned from different surgeons throughout surgical training. This difficulty might be overcome by a sparsely written atlas with simple line drawings to which notes and drawings can be added. A simple but seldom used solution is to write technical notes to yourself. This should not be a big deal-a simple loose leaf notebook kept in your surgical locker will serve this purpose. One page is devoted to each operation or topic (eg, fundoplication, bowel anastomosis). A brief outline for each operation would include (1) preoperation: notes on surgical indications, special preparations, bowel preparation, drugs, tubes, etc; (2) exposure: notes on the position of the patient, prepping and draping, position of the surgeon, assistants, and scrub nurse, the incision, types and position of retractors for exposure, etc; this overview is perhaps the most useful means for dissecting and analyzing an operation; (3) the operation in sequential steps: notes on the technical maneuvers written in schematic outline-it is helpful to divide complex operations into clearly defined steps with alternative approaches for each, drawings are helpful; and (4) closure and postoperative care: notes on tube and drain placement and special postoperative considerations such as when to discontinue antibiotics, remove drains, etc. These notes should be cryptic, jotted down in telegraphic style, and embellished with drawings and doodling. Complete sentences are disallowed, and the notes need not be intelligible to any other person. But the key to the surgeon’s notebook as a learning device is
From the Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, CA. Address reprint requests to Michael R. Harrison, MD. FACS. Department of Surgery, University of California, San Francisco, 3rd & Parnassus Aves. HSE-585, San Francisco, CA 94143-0510. o 1990 by W.B. Saunders Company. 0022-3468/90/2504-0021$03.00/0
379
380
discipline. Notes are made immediately after an operation, as automatically as dictating an operative note or changing out of your scrub suit. When an operation is first recorded, it may take 10 to 20 minutes to rethink the various steps and details and organize them in your notes. This is an extremely useful learning device in itself, since this will fix the operative steps in your mind and you will learn as much from one operation as 10 otherwise. However, the major advantage of this system is the ability to accumulate multiple details and multiple alternatives for each step of each operation, gleaned from years of training at different levels with different attending surgeons in different hospitals. It now becomes easy to note on the same page variations in technique, the advantages and disadvantages of alternative maneuvers, and finally, with experience, your own preference. The surgeon whose armamentarium includes a variety of techniques will have patients with fewer complications than the surgeon whose repertoire is limited to one way of dealing with a problem. This little notebook now becomes an extremely efficient way to accumulate a mass of small pieces of information and bring them all to bear on one particular step of one particular operation. As you progress during residency and begin to perform operations with less supervision, you should frequently review and embellish your notes. It takes only a few minutes while changing into scrub clothes to brush up on the details
HARRISON AND ADZICK
of the different steps of a complex operation that is infrequently performed. This permits mental rehearsal before the operation that will be the actual demonstration. You will soon be improving and synthesizing the various maneuvers you have learned. Your notebook will prove useful even in this period of consolidation. This learning system should not become a burden. It requires some discipline and only a few minutes of time to record the small technical details learned in the operating room. When nothing new is learned, nothing need be recorded. But, when small tricks are recalled and recorded, your appreciation of the surgical craft is enhanced. Operations are no longer a blur of retractors, tissues, and sutures, but a symphony of small precise steps that can be delineated, recorded, and assimilated into a masterful operation that is a technical joy. Some gifted residents may not need such a mechanism to help them remember and master the many technical nuances they are exposed to during the hundreds of operations performed during 5 to 10 years of residency. But most will find it useful. They will follow the example of such technical masters as Leonardo da Vinci and Harvey Cushing and keep a little notebook for themselves. Sincerely,
Your Fellow Surgeon