Take notes in the OR

At the pediatric surgery residents’ meeting at the AAP last week, one of the speakers, a new graduate who was scheduled to discuss strategies for negotiating an academic job, started off with completely unrelated, but precious advice for residents: read about your patients (and don’t just study for the boards), go to clinic (many pilomatrixomas will be seen in your office), and take notes in the OR. How is it that, as residents, many of us go through training without ever documenting, in our own words, what we are taught in the OR?!

I’m not sure whom I should give credit to for giving me this same advice at the time, but I have been taking notes in the OR since I was a third year resident. And when I say notes, I mean detailed accounts of the main steps, instruments used, suture etc…. I have two notebooks, one from general surgery residency and one from my current pediatric surgery training, filled with elaborate step-by-step instructions. Details about specific preoperative studies, how to prep and drape (attending specific!), exact instruments to use and at what point to switch, post operative management pathways, and follow up plans.

Writing notes helped me focus on and analyze the steps of an operation. I frequently found myself unsure of which step came first or which retractor was used for a specific exposure. The more notes I wrote, the more I paid attention to details I had missed before. I even found myself watching an operation just to be able to fill gaps in my operative notes when there was a step I could not recall.

When I started taking notes and reviewing them preoperatively during my general surgery training, I could not help but notice how positively my attendings reacted to the fact that I prep’d and draped EXACTLY as they did (detailed notes!). Prep right, ask for the exact suture and instrument, and you would be amazed how much more autonomy you may be given.

Those little gems that are mentioned in the OR that you cannot find in any textbook, many of which are the culmination of years of experience, should all be jotted down on the margins of the page next to the detailed list of steps.
“This is where you need to slow down and take your time along this corner, and switch the traction with your left hand to help with exposure” is not something you can find in an atlas, but something that should be written in permanent black ink next to a sketch or diagram.

Unlike a surgical atlas, my own account of how I learned to do a Nissen or a hernia repair will be much more relevant and useful to me when the time comes for me to do the same operation and ask for the next suture or retractor. There will be no time spent scratching my head when the scrub tech asks me what suture I want to close the diaphragmatic defect with or figure out what size clip I need for the PDA ligation. If I had not been taking notes, I might have not remembered that there was such a thing as a M-L clip (green); a clip that is smaller than the Large (orange) which can be too large, and larger than the Medium (blue) that can be too small. Something that would be great to know ahead of time when a preemie’s chest is open and no clip seems to be the correct size!

As a bonus, at the end of my general surgery residency, I asked my favorite attendings to review the notes I took of their operations, correct them as they wished, and sign them as a souvenir. Now, on my bookshelf, I have two of my most precious references and souvenirs from training. I guard them with my life!