Polite Dissent

Third year of medical school was divided into 3 “minor rotations” of 2 months each and 2 “major rotations” of 3 months each. The minors were OB/Gyn, Pediatrics, and Psychiatry. The majors were internal medicine and surgery. Surgery was then further divided into the A, B, and C courses. These essentially broke down as follows: A level was designed for students who knew that they wanted to be surgeons. It consisted of long hours, but offered the most chance of hands-on work and getting to know the right surgeons. B level was for students who were considering surgery as career choice, but hadn’t made up their mind yet. It still had a lot of hands-on opportunities, but it wasn’t quite as grueling as the A level courses. It also had more of the “romantic” aspects of surgery (trauma! transplant!) designed to sweep students off their feet. Finally, there were the C level courses. These were for students who were already certain that they weren’t going into surgery. Supposedly, it wasn’t as labor intensive as the A and B levels, and had more general interest rotations. By this time, I had already decided on Family Practice, and while I found surgery fascinating, I knew it wasn’t for me, so I went straight for the C level courses.

My three months of surgery consisted of, in no particular order: one month of Pediatric Surgery (rather boring; bland attendings and residents), one month of General Surgery at the VA (easily the worst month of my life, ever. We were horribly understaffed and the residents were as unhappy to be there as we were, and took it out on us.), two weeks of ENT (fun, but then I already knew all the attending and residents from bartending their Christmas party. But that’s another story), and two weeks of Vascular Surgery. Vascular was probably my favorite rotation. It consisted of two attendings, one resident, and me. They were very happy to teach and respected the fact that I was going into Family Practice. They went out of their way to make sure that I learned the aspects of vascular surgery that would be important in primary care.

That was a long set up for a very short story…

It was in a Vascular Surgery case that I was given my first chance to suture a patient all by myself. We were performing a carotid endarterectomy, and had used part of the saphenous vein for the procedure. While the surgeon was finishing up in the neck, he looked over to me and said, “Scott, why don’t you close up the leg incision?”

“Sure!” I said, almost confidently. A nurse handed me the proper gear and some suture and I got started. At the far end of incision, I threw in a stitch, tied a knot, and then worked my way up the incision, one subcuticular stitch at a time. Subcuticular stitches are done just under the skin and use absorbable suture, so they don’t have to be removed; they dissolve away on their own. It’s a zig-zag style of suturing, and the trick is getting the two sides to line up.

I was being extremely careful, making sure that both sides lined up, and ensuring that I did everything “by the book.” The end result, if I do say so myself, looked pretty good. Sure, one end was a little dog-eared, but the surgeon didn’t seem to mind (“Just throw a steri-strip on there!”). However, when I tied the final knot, I looked up and realized that the main surgery was long over and the entire surgical team had been watching me — for the past hour. Yes, it took me well over an hour to sew up what amounted to little more than a 4-inch incision. I was mortified. The surgical team were all good sports about it, but I was sure I had just flunked my rotation.

The surgeon gave me another chance to suture the next day, so I probably wasn’t as bad as I remember — or maybe I was, and he thought I needed all the experience I could get. Either way, he gave me a good grade at the end, so I like to think I finished the rotation with some decent suturing skills (though I haven’t use subcuticular stitches much since).