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What OR skills should I have by end of PGY2?
#1
What operating room skills should I have a by the end of PGY2 If my goal is to become a competent community neurosurgeon at the end of my seven years? I am not trying to become a master surgeon. I just want to be a good surgeon who can help the low complexity patients in my community

My goal is to be competent at positioning, exposure and closing on basic spine surgeries by midyear and then near full independence by the end of the year. For cranial cases, I hope to start opening dura by mid December.

Too conservative of goals? There still seems to be a lot of floor work as a PGY two unfortunately. What other peoples’ experiences?
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#2
Even with "basic" spine procedures, being fully independent it is not something you will achieve by the end of PGY2. It is always better to know when to stop and ask for help, instead of just trying to be independent. Even the easiest disc can become a disaster. Knowing your limitations it is actually more important if you want to become a community neurosurgeon.
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#3
seriously, if you're doing any bone work in spine by the end of second year, you're probably ahead of the game
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#4
full independence by end of the 2nd year? lol. nice.
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#5
(07-18-2020, 07:40 PM)Pgy2 Wrote: What operating room skills should I have a by the end of PGY2 If my goal is to become a competent community neurosurgeon at the end of my seven years? I am not trying to become a master surgeon. I just want to be a good surgeon who can help the low complexity patients in my community

My goal is to be competent at positioning, exposure and closing on basic spine surgeries by midyear and then near full independence by the end of the year. For cranial cases, I hope to start opening dura by mid December.

Too conservative of goals? There still seems to be a lot of floor work as a PGY two unfortunately. What other peoples’ experiences?

Let me try to help you cut thru the inevitable snark. First, this is incredibly specific to your program, its culture, its rotation setup, etc. There are some programs where residents don't see an aneurysm clipped until PGY4 simply because those cases happen at a specific hospital. Obviously, if you are only exposed to one type of case versus another, you should be further along for those cases. Second, your job as a junior is almost always to watch. There are those who are good at watching, and those who learn nothing. You are sorely mistaken if you think the only way to learn in the OR is to be operating. If you know the steps of basic operations (ACDF, hemicrani, shunt, etc.) without doing them, you will hit the ground running.

A few things I think are fairly generalizable:
- What your attendings probably tell you about really learning the basics could not be more true. Your junior residency is where good and bad habits are made. Watch your seniors and attendings who have seen wounds fall apart, post-op epidurals develop, and pressure ulcers cause lawsuits. If you don't learn those very basic things now, you likely never will or will do so the hard way.
- Any kind of EVD. Know your craniometric points.
- Master your wound closures. Understand why you are using the sutures and needles you are using, and why you might change your selection. Learn tactics to close revision cases. Learn what makes for good cosmesis. Closing is a technical skill like anything else.
- Open skin cleanly without beveling. You should be able to, with a single cut, feel with the knife and your tension on the skin edges when you cut thru galea, without violating pericranium, muscle fascia, or underlying vessels e.g. STA (not wanted by all attendings, but tests your skill)
- Turn a craniotomy - any kind not involving the posterior fossa. Burr holes with and without a perforator. Run the perforator without snagging. Develop a strategy for turning a craniotomy that crosses the sagittal sinus. The goal should be that you can get to dura before a senior scrubs into the case.
- Expose the thoracic and lumbar spine without violating facet capsules. Expose pedicle screw entry points. Understand the safe zones for drilling while your senior does a laminectomy.
- Learn basic soft tissue dissection techniques. Scissor spreading, proper use of the bovie, ligating vessels, etc. These are great to learn in peripheral nerve cases. They are ignored because our surgeries are so bone-focused but they will save your ass more than once.
- Insert a simple shunt. The belly is harder than the head, focus on it.
- Learn what it takes to be comfortable under the scope. You should know your personal settings and how to set it up and focus.


I'm sure there are more.
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#6
Not the OP...Nice advice and thoughts here...what about the expected goals by the end of PGY-4
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#7
Thanks for the replies. When I said independence, I didn’t mean complete OR room independence, but enough where the attending doesn’t need to do or say anything and can either hang about the room or chat with the vendors while I do more exposure.
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#8
(07-18-2020, 11:42 PM)Guest Wrote:
(07-18-2020, 07:40 PM)Pgy2 Wrote: What operating room skills should I have a by the end of PGY2 If my goal is to become a competent community neurosurgeon at the end of my seven years? I am not trying to become a master surgeon. I just want to be a good surgeon who can help the low complexity patients in my community

My goal is to be competent at positioning, exposure and closing on basic spine surgeries by midyear and then near full independence by the end of the year. For cranial cases, I hope to start opening dura by mid December.

Too conservative of goals? There still seems to be a lot of floor work as a PGY two unfortunately. What other peoples’ experiences?

Let me try to help you cut thru the inevitable snark. First, this is incredibly specific to your program, its culture, its rotation setup, etc. There are some programs where residents don't see an aneurysm clipped until PGY4 simply because those cases happen at a specific hospital. Obviously, if you are only exposed to one type of case versus another, you should be further along for those cases. Second, your job as a junior is almost always to watch. There are those who are good at watching, and those who learn nothing. You are sorely mistaken if you think the only way to learn in the OR is to be operating. If you know the steps of basic operations (ACDF, hemicrani, shunt, etc.) without doing them, you will hit the ground running.

A few things I think are fairly generalizable:
- What your attendings probably tell you about really learning the basics could not be more true. Your junior residency is where good and bad habits are made. Watch your seniors and attendings who have seen wounds fall apart, post-op epidurals develop, and pressure ulcers cause lawsuits. If you don't learn those very basic things now, you likely never will or will do so the hard way.
- Any kind of EVD. Know your craniometric points.
- Master your wound closures. Understand why you are using the sutures and needles you are using, and why you might change your selection. Learn tactics to close revision cases. Learn what makes for good cosmesis. Closing is a technical skill like anything else.
- Open skin cleanly without beveling. You should be able to, with a single cut, feel with the knife and your tension on the skin edges when you cut thru galea, without violating pericranium, muscle fascia, or underlying vessels e.g. STA (not wanted by all attendings, but tests your skill)
- Turn a craniotomy - any kind not involving the posterior fossa. Burr holes with and without a perforator. Run the perforator without snagging. Develop a strategy for turning a craniotomy that crosses the sagittal sinus. The goal should be that you can get to dura before a senior scrubs into the case.
- Expose the thoracic and lumbar spine without violating facet capsules. Expose pedicle screw entry points. Understand the safe zones for drilling while your senior does a laminectomy.
- Learn basic soft tissue dissection techniques. Scissor spreading, proper use of the bovie, ligating vessels, etc. These are great to learn in peripheral nerve cases. They are ignored because our surgeries are so bone-focused but they will save your ass more than once.
- Insert a simple shunt. The belly is harder than the head, focus on it.
- Learn what it takes to be comfortable under the scope. You should know your personal settings and how to set it up and focus.


I'm sure there are more.

Really not cutting the STA? In my program all attendings that I know they cut the STA in pterional or any incision that reaches close to the zygoma...now I am curious to know what is right and what is wrong
Reply
#9
(08-20-2020, 10:51 PM)Guest Wrote:
(07-18-2020, 11:42 PM)Guest Wrote:
(07-18-2020, 07:40 PM)Pgy2 Wrote: What operating room skills should I have a by the end of PGY2 If my goal is to become a competent community neurosurgeon at the end of my seven years? I am not trying to become a master surgeon. I just want to be a good surgeon who can help the low complexity patients in my community

My goal is to be competent at positioning, exposure and closing on basic spine surgeries by midyear and then near full independence by the end of the year. For cranial cases, I hope to start opening dura by mid December.

Too conservative of goals? There still seems to be a lot of floor work as a PGY two unfortunately. What other peoples’ experiences?

Let me try to help you cut thru the inevitable snark. First, this is incredibly specific to your program, its culture, its rotation setup, etc. There are some programs where residents don't see an aneurysm clipped until PGY4 simply because those cases happen at a specific hospital. Obviously, if you are only exposed to one type of case versus another, you should be further along for those cases. Second, your job as a junior is almost always to watch. There are those who are good at watching, and those who learn nothing. You are sorely mistaken if you think the only way to learn in the OR is to be operating. If you know the steps of basic operations (ACDF, hemicrani, shunt, etc.) without doing them, you will hit the ground running.

A few things I think are fairly generalizable:
- What your attendings probably tell you about really learning the basics could not be more true. Your junior residency is where good and bad habits are made. Watch your seniors and attendings who have seen wounds fall apart, post-op epidurals develop, and pressure ulcers cause lawsuits. If you don't learn those very basic things now, you likely never will or will do so the hard way.
- Any kind of EVD. Know your craniometric points.
- Master your wound closures. Understand why you are using the sutures and needles you are using, and why you might change your selection. Learn tactics to close revision cases. Learn what makes for good cosmesis. Closing is a technical skill like anything else.
- Open skin cleanly without beveling. You should be able to, with a single cut, feel with the knife and your tension on the skin edges when you cut thru galea, without violating pericranium, muscle fascia, or underlying vessels e.g. STA (not wanted by all attendings, but tests your skill)
- Turn a craniotomy - any kind not involving the posterior fossa. Burr holes with and without a perforator. Run the perforator without snagging. Develop a strategy for turning a craniotomy that crosses the sagittal sinus. The goal should be that you can get to dura before a senior scrubs into the case.
- Expose the thoracic and lumbar spine without violating facet capsules. Expose pedicle screw entry points. Understand the safe zones for drilling while your senior does a laminectomy.
- Learn basic soft tissue dissection techniques. Scissor spreading, proper use of the bovie, ligating vessels, etc. These are great to learn in peripheral nerve cases. They are ignored because our surgeries are so bone-focused but they will save your ass more than once.
- Insert a simple shunt. The belly is harder than the head, focus on it.
- Learn what it takes to be comfortable under the scope. You should know your personal settings and how to set it up and focus.


I'm sure there are more.

Really not cutting the STA? In my program all attendings that I know they cut the STA in pterional or any incision that reaches close to the zygoma...now I am curious to know what is right and what is wrong



Saving the STA is impossible?  ...how do you propose doing an STA-MCA bypass?

They're probably doing it for speed. But with practice you can be fast and not sacrifice it.
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#10
Seriously what are the expected skills/cases by the end of PGY4? In my program, we do the drilling/instrumentation of simple PCDF, laminectomies or lumbar laminectomies with attending heavily involved. For closing the attending leaves but I am concerned of this poor autonomy or this is how it's in most of other programs
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