Category Archive: General Surgery

Book Review. Better: A Surgeon’s Notes on Performance

In "Better: A Surgeon's Notes on Performance", Dr. Atul Gawande (General Surgeon, Brigham and Women's Hospital, Boston) attempts to provide the reader with a bird's eye view of what it takes to be better. He uses a vast array of interviews and historical perspectives to highlight what he believes are the pillars of become better in everything we do. Of course, the stories and perspectives revolve around medicine and hospitals, but you will be surprised to learn how diverse the various examples are in pinpointing what it means to become better. He uses examples of hospital teams improving the survival of patients with a certain disease, the historical accounts of improving health care through hand washing, an inspiring story of an attempt to eradicate Polio in India, and even a riveting tale of a physician-turned-malpractice lawyer who abandoned the stethoscope for law school. Though eclectic in their descriptions, each aims to hone in on the skills one needs to improve.

I think the goal of "Better" is noble. I also think the core content is interesting and through provoking. I even agree that physicians and medicine should be the ones to be pushing this envelope, trying every day to be better and to improve. It seems like this should be our job in society, if nothing else. And for this, I applaude Dr. Gawande and the goal of this book. However, I must admit that the product did not quite meet the goal of this book.

I have hesitated to write this review, because I know that so many other people, including many other docs, loved "Better". But, I must be honest and admit that this is not one of Gawande's better books. Perhaps I have held him up to an unhealthy standard after "Being Mortal", the book that got me started on Dr. Gawande, and one I think is a must-read for everyone, not just those in medicine. The problem with "Better" is that in the midst of all of its fascinating mini-stories (a hallmark of Dr. Gawande's writing) the actual goal of the book is lost on the reader. He can't quite pull all of the information together to drive home his ideas. It is almost as if he has not quite formalized the ideas of how to become better in his own head. For this I do not fault him. Certainly, he has come much closer to organizing the idea of improvement much better than I, or most other people can. But, unfortunately, mini-stories in this book are sporadic and, in the end, the sum of the parts of "Better" probably equals more than the whole.

Conclusion: "Better" by Dr. Atul Gawande is a good read, but not a must read. I give it a ShortWhiteCoat Step 1 score of 225.



Best Books and Resources for the General Surgery Rotation


This post is part of our series on the best books and resources to help you perform well on your third year rotations and shelf exams. Also check out our lists for clerkships in Internal MedicineFamily MedicineOB/GYNGeneral SurgeryNeurologyPsychiatryPediatrics, and Emergency Medicine. You can also check out our complete list of "Best Books" lists for medical students here

Background: Clerkship Grades

At the beginning of each of these clerkship lists there are a few things I must say. First, your grade on clinical rotations will depend on both your clinical performance and your performance on a shelf exam at the end of the rotation. While it is true that how you work with your teams and patients will play into your evaluation, there is no denying that your knowledge of the subject matter is, by far, the most important part of your final grade because it directly affects both of these two areas of evaluation. As a resident, I currently find myself filling out medical student evaluations every week. There are very few 'incredible' medical students and very few 'terrible' medical students. The vast majority of you (~95%) fit into the "good and easy to work with" group; the only thing you have to set you apart from others is your knowledge base. You have no alternative but to study! First Aid for the Wards is a great resource to understand the dynamics of your clinical rotations, I highly recommend it.

Essential Resources

The resources I will describe in the clerkship lists are books and online question banks. From the onset let me point out two indespesible resources that I will not list for each rotation individually.

  • First, I consider a great online question bank essential. Both Kaplan and USMLE World are very good products. I highly recommend purchasing a one year subscription to one of these USMLE Step 2 question banks. As you complete your third year rotations, these question banks will prepare you for 1- your clinical duties, 2- your rotation shelf exam, and 3- the USMLE Step 2 during your fourth year.  
  • Second, online review materials (e.g. Medscape, UpToDate, etc.) are essential resources to prepare for your patients in the hospital. The books and question banks can never provide the type of in-depth detail about disease processes that you will need to learn how to properly take care of your specific patients. To be a great medical student, you must prepare more profoundly for the diseases you are encountering personally in the hospital.

Book Series for Third Year

Medical students are not all made the same; we are all very different learners. There are a number of companies producing review materials for third year medical students, each with a slightly different focus. Each of these companies produce a different book for each clerkship. Interestingly, some companies' books are rated higher in some clerkships than others. If you find a product that works for you, consider sticking with it during your third year even if that product is not 'rated' as highly for a specific clerkship. Below are a few of the review products and their features.

  1. The Case Files Series: A unique teaching model; the Case Files series introduces a number of important clinical cases and follows them up with clinical pearls and important concepts. For students who need vivid clinical situations to remember factoids and concepts, this is a great series. (Case Files Surgery)
  2. The PreTest Series: The PreTest series is a classic question bank format with questions and detailed explanations. As I previously mentioned, I believe there is no substitute for a great question bank. While an online resource (USMLE World or Kaplan) can be more robust and mobile, a good question book is still a great option. The PreTest series produces a couple fantastic question banks. (PreTest Surgery).
  3. The BluePrints Series: The BluePrints series has a beautiful format that is very easy to read. The text is laid out in a bulleted lists, but with more details and descriptions than the First Aid series with which most students are familiar. I think very highly of these review books. (Blueprints Surgery).
  4. First Aid Clerkship Series: The First Aid series well known to most students also produces review books for third year clerkships. The content is similar to what students are used to, bulleted lists of high yield information. While I highly recommend many of the First Aid review books for USMLE Step preparation, the books are not quite as widely read and recommended for clerkships. (First Aid Surgery).

Best Books for General Surgery Rotation

So, we can agree that books are not sufficient for success on your clerkships, but they are still an incredible resource that you should tap into. Let's review the best books and resources for your General Surgery rotation. These lists come from both my experience and also from one medical school's annual survey of its 250 graduating medical students who try to detail which resources were the most useful on their rotations.

The General Surgery clerkship is unique in that the most highly recommended books and resources are completely different than for all other rotations. In fact, none of the book series mentioned above are very highly recommended for the general surgery rotation. One reason for the difference is that you will not only have to prepare for the shelf exam and hospital rounds, but you will also need to prepare for pimping in the OR, which is a total different animal. Below are some resources that will help


1. Dr. Pestana's Surgical Notes:

Dr. Pestana's book started as a pdf document that was passed around nearly every medical school in the country. His insight into high yield topics in general surgery is unmatched. His clinical scenarios are all relevant and his explanations are all clear and concise. I consider this a must-have resource for medical students.  


2. NMS Surgical Casebook:

One of the most widely used clinical resources, the older edition of the NMS Casebook is known and respected by almost every graduating medical student. The reception of the new edition (linked to the right) is still to-be-determined. The casebook portrays clinical scenarios commonly seen in the OR and on the post-operative floors. It is a great companion to the NMS Surgery Textbook, which is a more complete review of clinical and operative general surgery.

3. Surgical Recall:

While question banks and text books will help students prepare for the clinics, wards, and shelf exam, they are not great resources when preparing for the operating room. I found Surgical Recall to be an excellent resource to prepare for intra-operative pimp sessions.


4. Case Files Surgery:

The CaseFiles Surgery volume is a quick read and could be a very good resource at the beginning of your rotation so that you get a broad introduction to common surgical problems. However, it is not sufficient for the shelf exam and will not prepare you very well for specific operating rooms.


Top Ten Books for Surgical Interns

This list is part of a series of articles about the best books for medical students. Click on the Med School Books Main Page to see other lists including the best books for each year in medical school, the best books for each clinical rotation, and the best books for USMLE Steps 1, 2, and 3.

The surgical internship is unique in that you will care for the full spectrum of patients: acute surgical patients, post-operative patients, patients with chronic illness, and very sick patient in the ICU. The surgical intern is truly a "Jack-of-all-trades" physician and must be able to reconcile huge med lists, manage diabetes, identify an acute abdomen, and take care of acute electrolyte changes in the ICU.

These are tall orders for a newly minted doctor. And don't forget, after 7am you will likely be the only one on the floor while the rest of your team heads to the operating room. Having the right books is one easy way to calm some of the inevitable anxiety. After much discussion with interns and residents at my last two hospitals, I have compiled the following Top Ten Books for Surgical Interns. These books are also great resources for preliminary surgery residents, or other surgical supspecialistis completing a general surgical internship. Most of the general surgery residents I spoke to agree that this list remains the same into their entire residency. Good Luck!

  • Updated May 2015

1. The Mont Reid Surgical Handbook:

The Mont Reid Handbook is a great reference tool to keep in your pocket or on your phone. It was written by a group of surgical residents and is very high yield. It will cover the majority of issues you run into while managing the floors during a surgical internship. It is also great for reviewing for OR cases…if you get to see any during your first year.

2. Surgery On Call:

Surgery On Call is another great pocket reference. The goal of this book, however, is more in the initial evaluation and treatment of surgical patients. The quick-reference format is great for a quick consultation. Some interns also suggest Surgical Recall , which has a similar format but is geared more towards 3rd and 4th year medical students. 

3. A Textbook: Cameron, Current Surgical Therapy:

Every surgery resident, even surgical interns, will benefit from a great surgery text. Many of you will be provided a text at the start of residency, so ask your department before investing hundreds in one of these books. Cameron's Current Surgical Therapy is the highest rated by surgical residents. However, there are other great options. Greenfield's Surgery is well-regarded and cheaper than Cameron's. There are also many people who swear by the Sabiston Textbook of Surgery

4. Tarascon Pocket Pharmacopedia:

While we all have access to online pharmaceutical indexes during residency, I agree with most interns and residents that a pocket manual like this great Tarascon book is far faster and more reliable than most online resources.

5. The ICU Book:

You really should get an ICU book. You can get through your first month as an intern in the SICU or MICU without one of these books, but they make your life so much easier that it is just not worth it. Even if you just read through it a few weeks before starting in the ICU, the information will be fresh on your mind and will help you a lot. This is the ICU book I used, it addresses both medical and surgical intensive care issues. Many residents also like The Little ICU Book

6. The Washington Manual Internship Survival Guide:

This is a lesser-known internship manual written by the same people who developed the highly rated medication reference, The Washington Manual of Medical Therapeutics. Not as well known as the Mont Reid manual, this is a book from a similar mold with a small but vocal cult-following.  

7. Zollinger Atlas of Surgical Operations:

A surgical atlas is the best way to learn the anatomy and prepare for pimping in the OR. A great surgical atlas will become one of your most important references during residency. If you are a general surgery resident, Zollinger's is the go-to atlas for most residents. 

8. Operative Dictations in General Surgery:

Dictating operative notes is a necessary evil. It has to be done, and it has to be done well for documentation purposes. As the low man on the totem pole, the job of dictation will fall on you. This is a highly recommended book to help interns and residents early in their career. I have a number of procedure note templates available on this website.

9. The ABSITE Review (FISER):

Many surgical interns will complete residencies in specialties other than general surgery. For those of you moving on the general surgery after your internship, you should start studying for your ABSITE early. I know you are incredibly busy in the hospital, but when you have a minute you should keep an ABSITE review book and/or question book handy. The Fiser review comes highly recommended. Another book that many residents recommend is ABSITE Slayer.

10. Old-School and Out-of-Print:

After discussing books for surgical internship and residency with many people, there were two books that were mentioned many times but are no longer in print: The Cleveland Clinic Guide to Surgical Patient Management and The Surgical Intern Pocket Survival Guide . These two books come as high or more highly recommended than every other book on this list. Some residents say these were the most used books in their white coats. Unfortunately, you can no longer buy either of them new, but there are many used options.  


Which Residents Work the Hardest?

No one will ever agree on which residency is the hardest, or which residents work the most. However, with some new data from the FREIDA website, we get a better idea than ever before.  (For more information about the FREIDA website, read my previous article) FREIDA reports diverse variables about each specialty including the average of numbers worked per week, the average number of days off per week, and the average vacation time of each specialty.  I have compiled these into one database so that for THE FIRST TIME EVER you can compare objectively which residencies work the hardest.  (Well, at least you can compare which work the longest).

The first figure demonstrates the average number of hours worked by each specialty. As expected, the surgical sub-specialties work the longest hours with neurosurgery leading the pack and general surgery following closely in second.  Of the medical specialties, suprisingly, neurology works the most hours, with pediatrics and internal medicine following close behind. And at the bottom of the list… you guessed it, Dermatology. I wish I loved skin!

The results of the average number of days off per week and the average vacation time during residency follows closely with the trend seen in the graph above. For your viewing pleasure I have the entire compiled dataset posted below.  






Hours worked per week

Days off per week

Vacation weeks per year





Nuclear Medicine




Medical Genetics




Radiation Oncology
























Emergency Medicine




Transitional Year




Colon and Rectal Surgery








Family Medicine




Internal Medicine




















Orthopaedic Surgery




Obstetrics and Gynecology




Plastic Surgery




Vascular Surgery




Thoracic Surgery




General Surgery




Neurological Surgery






Spotlight Interview: Matching in General Surgery


A General Surgery Resident’s Perspective:  From an interview with a general surgery resident at Orlando Health in Orlando, FL

Part of an interview series entitled, “Specialty Spotlights“, which asks medical students’ most burning questions to physicians of every specialty.  See what doctors from every specialty had to say about why they chose their specialty and how to match in their residency.


  • How competitive is the general surgery match?

Moderately difficult. The average USMLE Step 1 score is usually in the high 220s, but higher for the sought after programs.


  •  What must a student do to match well in general surgery?

Your USMLE Step 1 score is the most important factor. Letters of Recommendation are very impotant and some should come from surgeons you have worked closely with. If you are interested in a research institution then research publications and presentations are very important.


  • What are residencies looking for in a general surgery applicant?
They are looking for someone who is Intelligent; they use Step 1 scores to establish this. They are also looking for someone who is passionate and hard-working; they can learn this through the activities you list and from the things mentioned in your letters of recommendation. It is important to be easy to work with, you can show this to programs during your interview.


  • What should students look for in a general surgery residency?

From a training standpoint, I think that surgical simulation experiences and structured education lectures/curriculum are something that every applicant has to be aware of. These experience are paramount in your surgical training. As you probably know, operative experience volume and variety is one of the most important factors (i.e. how many mastectomy vs whipple cases). You should know these statistics about each of your programs of interest.


  • Do you have any advice on the application, letters of recommendation, personal statements, or how to rank programs?

Letters of recommendation should be from faculty that can speak to your strengths in clinical decision-making and surgical skills. Personal statements should not be about how you always wanted to be a surgeon, but why you decided to be a surgeon. Rank programs that provide you with a high operative experience and well-defined simulation/education curriculum


  • What do you wish you knew before application/interview season?  

Be sure to prepare your  letters of recommendation early. Plan to interview at about 10-15 programs. If you plan to interview at highly competitive programs, you might need to plan on a bit more interviews.

Editor’s Note: I 100% agree with preparing your LOR early.  Many of the attendings are extremely busy and 1 month notice may not be enough. Start asking at the end of your third year if you find individuals who could write great letters.


  • What other advice do you have for students applying to general surgery residency?

The best advice I ever received about deciding to do general surgery was “If you can’t do anything but general surgery and be happy as a physician then you should do surgery. Otherwise do the other specialty”. General surgery is a much more family-friendly specialty than it used to be. The egos and personalities that used to predominate the specialty are gone, surgeons are expected to be calm and mild-mannered today and exist well with their non-surgical counterparts. The best part of being a surgeon is being able to diagnose and treat the problems our patients face. When all other options fail and other specialties are uncertain what to do they will consult a surgeon to help, so you will be the go-to person where-ever you practice


Editor's Note: Applying for residency or preparing for your interviews? I highly recommend First Aid for the Match, The Successful Match: 200 Rules to Succeed in the Residency Match, and The Residency Interview: How To Make the Best Possible Impression .


Spotlight Interviews: Why did you choose general surgery?

A General Surgery Resident’s Perspective: From an interview with a general surgery resident at Orlando Health, in Orlando, Florida.

Part of an interview series entitled, “Specialty Spotlights“, which asks medical students’ most burning questions to physicians of every specialty.  See what doctors from every specialty had to say about why they chose their specialty and how to match in their residency.


  • What attracted you to General Surgery?

I appreciate the combined operative and medical management of patients. Surgeons make definitive management of patient issues. There is a great variety of operative procedures. As a general surgeon I am able to care for both long and short term patient management scenarios. There is a great deal of job opportunities and availability. I enjoy team-based patient management.


  • Describe a General Surgeon’s typical work day?

I usually wake up at 0400,I am at hospital by 0500 to round on patients until about 0700. I will be in the OR from 0700 until about 1600 with intermittent 30-60 minutes breaks between cases to eat, follow-up on patients, and see new consults. From 1600-1800 we follow-up on outstanding patient issues and setup for following day. On good days, I return home and from 1800-2000 I study for following day cases and current patient problems. On non-operative days, simply change the OR times  to clinic from 0800-1600.


  • What type of lifestyle can a General Surgeon expect?  

As a general surgeon I work weekends at least 2-3 times per month. The amount of free time you will have is extremely dependent on your sub-specialty choice. Private practice surgeons enjoy significantly more free time while surgeons in academic practice spend more time with research and have less operative/clinic time generally. Call is usually taken for 24 hours periods and you will be working most of the day and night. Some surgeons have a tendency to scheduling elective cases during their call days, but this depends on how difficult your call is.


  • What is the average salary of a General Surgeon?

The overall salary of a surgeon is highly variable amongst sub-specialties, typically  between $250,000-$500,000.


  • What is the job market like for General Surgeon?

There is no lack of general surgery positions. I would say they are extremely available for both private practice and academic positions. There is some variability among sub-specialties. However, overall, we are one of the most high recruited specialties.


  • What can you tell us about General Surgery Sub-specialties?

Residency for general surgery is 5 years mandatory and more commonly 1-2 years research years during PGY2 or 3. Therefore, many general surgery residencies last 6-7 years before fellowship. Fellowships typically last 1-2 years. Subspecialties have more call and higher salary. Additionally, sub-specialties are generally in more demand than general surgeons.


  • What are the potential downsides of General Surgeon that students should be aware of?

The schedule is less flexible due to emergent surgical problems. Surgical shift hours are not reliable and typically cases will be delayed or run over and require staying at the hospital beyond a call or shift. This leads to a schedule that can be variable. Training programs are not as “intense” as they were historically, although there are still high expectations of surgical residents. There are not many other residents/doctors who work as hard as general surgeons.


  • What else would you tell medical students who are considering General Surgery?

One thing students should realize is that there is more peri-operative management being handled by hospitalist services for elective surgical problems. Therefore, some of the duties and responsibilities of a surgeon 20 years ago and being placed in the hands of non-surgeons. Additionally, surgical critical care services are beginning to  limit the medical management requirements of general surgeons.



Editor's Note: For more help choosing a specialty in medicine, I highly recommend one or both of these two great books. I found both very useful.


Physician Satisfaction by Specialty

The most recent installment of the Medscape Physician Compensation Report was recently published. Along with some of the best information on the web about physician salaries by specialty, the new Medscape report also reports which specialties are the most satisfied with their jobs (click here to view the entire Medscape Report). The results may surprise you. There is no correlation with salary and satisfaction.  The highest paid specialties (orthopedics and anesthesia for example) are found in the middle of the list while pediatrics, ID/HIV, and pathology are all found at the top of the list.  Interestingly, plastic surgery is–by far–the least satisfying specialty. So, the most competitive specialty is by far the least satisfying…that’s odd!


From the 2012 Medscape Compensation Report


My conclusions from the Physician Satisfaction Survey:

  1. The age old adage is correct: Money does NOT buy happiness.
  2. Just because a specialty is desirable to match into does not mean it is desirable to practice in [plastics].
  3. I can find only one thing that links the most satisfying specialties: LIFESTYLE.  If you look at dermatology, psychiatry, emergency medicine, infectious disease, pathology, and ophthalmology they have a great lifestyle in common. They all have minimal call, good salary (but they are not the big earners), and few emergencies.  They all lend themselves well to family, recreation, and other hobbies outside of medicine.


My unsolicited advice:

  • I am sure there are my internists and plastic surgeons who are very satisfied with their jobs. I would bet that they knew exactly what there were getting into before they choose their specialty. Satisfaction in the workplace has lots to do with managing your expectations (and the expectations of your family and friends!)  If you really love some of the specialties that do not have the best lifestyle, that is great, just make sure you know that this will be an issue before you go into he specialty. Once you have made that decision, you will not be shocked (and neither will your family/friends) when you work a lot more than those around you.

The Most Recruited Medical Specialties

Now that I am in the first year of residency I am beginning to think about landing that first real job.  As a Transitional Year resident I am heavily involved with the Internal Medicine residents at my hospital.  I found out very quickly that these internal medicine residents are HIGHLY sought after. In fact, many of them receive job offers on a weekly, or even daily basis.  The jobs that are in highest demand for internists are outpatient primary care and inpatient hospitality.  Many of my senior residents are being offered salaries between $200,000 and $300,000 along with many benefits including loan repayment. There are even some offers higher than $300,000 for less desirable locations! This is in a stark contrast to the ophthalmology job market that I will face, where starting salaries are low and it is terribly difficult to get your foot in the door.

Recently, I came across the Merritt Hawkins database.  Merritt Hawkins obtains information about starting salaries and benefits for newly graduated residents. I speak about their great physician salary database in my Ultimate Guide to Physician Salaries. However, their database also contains a list of the 20 most recruited specialties in medicine. The list may shock you!  The ability to find a well paying job right out of residency is NOT AT ALL correlated with the competitiveness of the specialty.  Case in point: family physicians and general internists are the two most highly recruited specialists in medicine!

From Merritt Hawkins


This list represents the Top 20 most ‘requested physician searches by medical specialty.’ The numbers represent the number of times Merritt Hawkins was used to recruit a person from the respective specialties (Merritt Hawkins full PDF including physician compensation data is available here for free). So, when you are deciding on a specialty, don’t forget that competitive does not equal good job placement.  In fact, many of the least competitive specialties are very high on this list (pediatrics, psychiatry, family medicine)

Which doctors get sued the most?

Have you ever wondered which physician specialties deal with the most malpractice lawsuits? While I was in medical school I often heard physicians discuss the rising costs of malpractice insurance and the lack of tort reform.  I knew that OB/GYN doctors had to deal with a lot of lawsuits, but I had no knowledge of which other specialties faced frequent lawsuits.  The New England Journal of Medicine recently published a great paper identifying which medical specialties are sued the most frequently.  The paper can be freely accessed by anyone (click here to see the full article).

The most interesting results can be summarized by the graph below, which demonstrates the percentage of physicians sued in a calendar year, separated by specialty. As you can see, neurosurgeons and cardio-thoracic surgeons lead the list with nearly 20% of all physicians in these specialties sued each year.  Wow, that seems excessive!  On the other side of the graph, only about 3% of psychiatry and pediatric physicians deal with lawsuits each year.

Taken from NEJM, click the link below to see the full article

See the full article here

The article also presents data that demonstrate the cumulative probability of being sued during your career.  They find that by the time physicians in ‘high risk’ malpractice fields, such as general surgery and neurosurgery, reach 55 years of age nearly every singly physician has been sued at least once (95-99%).

Malpractice lawsuits are an important topic, especially when choosing a medical specialty during medical school.  Students need to know what problems the every-day doctors face so that we can make informed decisions.  If someone went into neurosurgery without knowing that nearly 100% of all neurosurgeons will be sued by the age of 55, this might result in a very unhappy professional life.  On the other hand, if you love neurosurgery and you are informed about this problem, you will be able to weigh all the pros and the cons of the specialty before making your decision.  When you know what you are getting into, you always have a higher chance of success.