As a medical student, I had nightmares about my first day in the OR: scrubbing incorrectly, contaminating a sterile field, forgetting the anatomy I had so carefully studied the night before. It seemed like the only thing I could do in that artificially lit room was mess up. After a few cases I came to love the routine and ceremony of each surgery: the timeout; the rhythmic pattern of suture, tie, cut; the elegant dance of a skilled surgeon and his or her team successfully completing a procedure.

While being in the OR may not be part of everyone’s ideal career, it can be a meaningful and effective learning environment for everyone. Here are my pearls on how to be a medical student, in the OR.

The night before the case

You should have these three things figured out before any case. This will help orient you to what is going on and what to review the night before.

1. Where. What body part does the surgery involve, including blood supply, nerves, ligaments, and parts of the organ/structure. (i.e., ovarian cystectomy: pelvis, ovary, abdominal wall)

2. What. What is the exact procedure being performed? (i.e., ovarian cystectomy (removal of cyst), possible oophorectomy (removal of ovary))

3. Why. Why is the surgery being performed now? Why will this surgery help the patient? (i.e., scheduled, patient failed medical/conservative management, continued pain; risk of torsion, low risk for malignancy)

Reading the procedural steps can orient you to the procedure and important anatomy. Pay particular attention to warnings about avoiding structures (like the ureter), which make good medical student questions in the OR.

Know everything about your patient

Your resident is often taking care of multiple patients and trying to master surgical skills. Though they looked over the patient’s H&P at 5:15 a.m., they may not remember the minute details. While there is no need to memorize numbers, you can help the team by having a cheat sheet for each patient with patient information readily available.

The day of the case

Introduce yourself to the patient and their friends/family members. Thank them for letting you be involved. Remember, while you are excited to see a surgery, they are likely not thrilled about having surgery: keep your tone appropriately serious.

The OR staff is responsible for making sure the patient is safe. When you introduce yourself to everyone, including the scrub/circulator nurses and anesthesia, you help them help you be part of the team. A well-timed introduction will go a long way.

Be a team player

There are infinite tasks once a patient rolls into the OR. Jump in where you can: remove the stretcher from the room, place the SCDs on the patient’s calves, help write the post-operative note.

During the case, your role is assisting: holding retractors, blotting, suctioning, cutting. Learn the patterns of your surgical team, and anticipate what the surgeon needs next: blotting the subcutaneous tissue does not help the surgeon close the hysterotomy. When you need an instrument, hold your hand out, palm open, and ask matter of factly. Demonstrating your skills as an assist shows everyone you are ready for more responsibility.

Never scrub longer than your resident

At some point, it became a truism that students should scrub longer than their seniors. I tell my students the opposite. If you scrub longer than me, you’re no longer by my side, and I can’t help you. While not all residents feel the same, try to stay close to your resident throughout the case so they can provide guidance.

Keep your hands to yourself

Until it is your turn to get gowned and gloved, keep your hands together at shoulder level. Anything else risks the wrath of the sterility police, and will result in re-scrubbing. Once the patient is draped, plant yourself: put your sterile gloves on the sterile field. Keeping your hands grounded will make you look (and hopefully feel) calm.

No déjà vu

If you don’t know the answer to a question you’re asked during a case, look it up. Getting the same question wrong twice demonstrates you are not engaged with your learning. Show you took time to explore the material by asking a thoughtful question later. Similarly, if someone asks you to do something, whether adjust the light or hold your needle driver at an angle, carry that forward. No one likes to ask twice!

Follow-up

If you are part of someone’s case, stick with them through their entire hospital course. You will learn from their post-operative symptoms, the care they receive, the physical and emotional challenges they face. Ask patients about their decision to have surgery, their recovery, and their experience. Patients will appreciate the extra TLC, and the team will appreciate your efforts.

Taking care of patients is a privilege

Most importantly, remember that being a part of someone’s surgery is not just a learning opportunity. For many patients, surgery is a terrifying undertaking, which evokes fear of pain, vulnerability and even the threat of death. You should view each case as a privilege: much like the cadavers from medical school, these patients are volunteering a part of themselves so that you can be a better doctor. You will see these patients naked, under anesthesia, calling out in pain, and literally on the inside. You will see them in ways the people closest to them never will. Respect their bodies and their gift to you. Prepare for your cases so you can glean as much as you can. Contribute to the patient’s care. Take care of the patient when they wake up.

While the OR may feel more like a stage than a classroom, I hope this list helps you navigate your surgical rotations with a little more confidence and a little less anxiety. Here’s wishing you a meaningful, educational, and even enjoyable experience.

M. Alexandra Friedman is an obstetrics-gynecology resident.

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