Excel in Clinical Rotations: A Guide for Preliminary Surgery Residents

Understanding the Role of Clinical Rotations in a Preliminary Surgery Year

A preliminary surgery year is unique. Unlike categorical residents, you may not be guaranteed a full surgical training slot, but you are held to the same clinical expectations during your rotations. That reality can feel both motivating and stressful.

Clinical rotations during a prelim surgery residency are where your reputation, evaluations, and letters of recommendation are built. They also shape how program directors, attendings, and senior residents advocate for you—whether that’s for a categorical surgery position, another specialty (e.g., anesthesia, radiology, PM&R), or a transition to a different program.

For many, the prelim year is the bridge between medical school clerkships and long-term residency training. Your experience in third year rotations laid the foundation—now you have to perform at a higher, faster, and more independent level. Understanding this context helps you set realistic expectations and deliberate goals.

Key purposes of your clinical rotations in a preliminary surgery year:

• Demonstrate reliability and work ethic under real resident-level workload
• Develop core surgical skills: pre-op and post-op management, basic procedures, OR workflow
• Clarify your long-term trajectory: surgery vs. other fields
• Earn strong, detailed evaluations and letters of recommendation
• Build your professional network within surgery and across other departments (ICU, medicine, ED)

Think of every rotation as an extended audition—both for yourself (is this the right path?) and for future programs that may consider you for advanced positions.

---

Core Mindsets for Excelling as a Prelim on Rotations

1. Own Your Role, Even If It’s Temporary

It can be tempting to see a prelim surgery residency as “just one year,” especially if you already know you’ll be switching specialties. But patients, attendings, and co-residents need you to show up as fully as any categorical intern.

The most successful prelims:

• Act like they belong: They take accountability for their patients and their learning.
• Avoid “I’m just a prelim” language: Instead say, “I’m the intern on this service, and I’ll follow up on that.”
• Invest fully in the team: This includes pitching in for cross-coverage, notes, and call, even when it’s hard.

Attending surgeons often say: “If I didn’t know they were prelim, I’d assume they were categorical.” That’s the standard.

2. Adopt a “Resident-Level” Work Ethic

Your medical school third year rotations probably emphasized showing up on time, reading about your cases, and asking good questions. As a prelim surgery resident, the bar is higher and more granular:

• On time = early: Aim to arrive early enough to review overnight events, check labs, and be ready for sign-out—not walking in at sign-out time.
• Stay until the work is done: Even when your duty hours could technically justify going home, if your team is slammed and you’re still learning, staying (within duty hour rules) builds trust and credibility.
• Volunteer strategically: “I can discharge Ms. X and call the SNF,” “I’ll update the family about the plan,” “I can place that order and document the change.”

3. Be Coachable and Non-Defensive

Prelim surgery interns are under a microscope. People know you’re new, and they expect a learning curve. What gets you into trouble is not mistakes themselves, but how you respond to feedback.

• Acknowledge and adjust: “Thank you for pointing that out. I’ll change the way I write post-op notes and run my plans tomorrow.”
• Clarify, don’t argue: “To be sure I’m understanding: for POD1 after lap chole, you’d like daily LFTs or just if there’s concern?”
• Close the loop: At the end of the week, you might say to your chief, “I’ve been focusing on more concise presentations since your feedback—does this feel like an improvement?”

This mindset turns every clinical rotation into a personalized curriculum.

---

Mastering the Day-to-Day: Practical Strategies for Rotations

Pre-Rounding: Start the Day Ahead

Pre-rounding is where you demonstrate organization and clinical awareness. Your goal: walk into morning rounds knowing your patients better than anyone else at your level.

Checklist for effective pre-rounding:

1. Before you hit the floor

   • Review vitals trends (not just overnight but last 24–48 hours).
   • Check labs and imaging results; note what’s pending.
   • Look at I/O, drain outputs, stool, and urine output.
   • Skim overnight nursing notes and cross-cover notes.

2. At the bedside

   • Conduct a focused exam relevant to their surgery (abdomen, incision sites, extremity perfusion, neuro status, etc.).
   • Ask target questions: pain control, nausea, flatus/BM, ability to ambulate, diet tolerance.
   • Confirm drains, tubes, lines, and dressings are as documented.

3. Build a concise plan

   • Think in systems: neuro, cardiac, pulmonary, GI, GU, ID, DVT prophylaxis, lines/tubes/drains, discharge planning.
   • Align your plan with the “post-op day” and procedure-specific expectations (e.g., when to advance diet, when to remove Foley, when to switch from IV to PO meds).

Example:
You are on a colorectal service. A patient is POD2 after a low anterior resection. When you pre-round, you recognize they are tachycardic (HR 110) with low-grade fever and increasing abdominal pain. Rather than just reporting vitals, you might say during rounds:

“Mr. J is POD2 s/p LAR. Overnight he developed tachycardia to 110 and temp 100.6. Exam shows increased diffuse tenderness without rebound; his abdomen feels more distended than yesterday. WBC is up from 9 to 14. I’m concerned about possible early anastomotic leak or ileus. I’d suggest getting a CT with IV contrast and keeping him NPO with IVF while we reassess.”

That level of synthesis shows growth from “medical student” to “surgical intern.”

Presenting on Rounds: Be Clear, Concise, and Surgical

Your oral presentations are a critical part of clerkship success as a resident. Strong presentations allow your team to make faster decisions and build trust in your clinical judgment.

Structure for a daily surgery progress note/presentation:

• One-line summary: “Ms. K is a 54-year-old with perforated sigmoid diverticulitis, POD3 s/p laparoscopic sigmoid colectomy with primary anastomosis.”
• Overnight events: fevers, hypotension, new pain, PRNs, blood products, rapid responses.
• Objective data: Vitals trends, I/O, drains, labs, imaging.
• Focused exam: Start with “relevant positives and negatives,” not an exhaustive organ-system recital.
• Assessment & plan: Organized by problem, with a succinct phrase of reasoning.

Pearls:

• Give trends rather than isolated numbers—“Creatinine is up from 0.9 to 1.4 over 24 hours” is more meaningful than “Cr 1.4.”
• Translate data into action—“Given the rising creatinine and low urine output, I’d like to check a bladder scan and consider a fluid challenge.”
• Avoid reading off your note. Glance when needed; speak as if you understand the story.

In the Operating Room: From Observer to Valuable Team Member

The OR is central to a prelim surgery residency, but your contributions there will depend on preparation, situational awareness, and humility.

Before the case:

• Know the indication and key anatomy: You don’t need to recite an entire textbook, but you should know what disease is being treated, the operative steps at a high level, and the main structures at risk.
• Review imaging: Look at CT scans, angiograms, or ultrasounds yourself and be ready to discuss major findings.
• Understand your role: Ask your chief, “What’s my role in this case? Anything you want me to especially focus on?”

In the case:

• Help with positioning and prepping; anticipate needs (e.g., foley, SCDs, padding).
• Maintain sterile field awareness; avoid contaminating drapes or instruments.
• Offer to close skin or do simple tasks when appropriate, especially as you build trust.
• Ask questions, but time them well—avoid talking during critical steps like vessel ligation or anastomoses.

After the case:

• Write a concise post-op note with key details: procedure, complications (or lack thereof), EBL, drains, Foley, pain control plan, antibiotics, DVT prophylaxis, diet, and any special instructions (e.g., neurovascular checks).
• Check on the patient in PACU/ICU and communicate with families as appropriate, with your attending’s or chief’s guidance.

Documentation: Efficient, Accurate, and Legible

Good documentation underpins safe patient care and solid evaluations.

Tips for efficient notes on busy services:

• Use smart phrases/templates where allowed, but customize assessment and plan.
• Avoid “copy-paste errors”—old vitals, wrong POD, conflicting statements.
• Document clinical reasoning briefly, not just actions: “Holding anticoagulation due to expanding thigh hematoma; will reassess after repeat H/H.”
• For consults, clearly state reason for consult, your assessment, and recommendations in bullet form.

Strong documentation makes cross-cover easier, reduces pages from nursing, and signals to attendings that you understand your patients holistically.

---

Communication, Teamwork, and Professionalism

Working with Seniors and Attendings

Your relationships with seniors and attendings can transform a challenging prelim surgery residency into a launchpad for your career.

How to build trust:

• Be predictably reliable: If you say you’ll call a consult by 11:00, do it by 10:45 and update your senior.
• Pre-empt questions: When you tell your chief about a fever, already have the relevant data—cultures, imaging, exam—ready.
• Ask for expectations early: “On this trauma rotation, what do you expect me to own day-to-day?”
• Accept criticism professionally: Even if feedback is delivered bluntly, focus on what you can apply.

Earning strong letters and advocacy:

• Identify 1–3 attendings per rotation who see your work regularly.
• Let them know your goals: “I’m a prelim interested in matching into categorical surgery next year. I’d appreciate any feedback that can help me grow.”
• Towards the end of the rotation, if rapport is strong, ask directly if they’d be comfortable writing you a strong letter when the time comes.

Collaborating with Nurses, APPs, and Other Services

Clerkship success at the resident level depends heavily on interprofessional collaboration.

Nursing and APPs:

• Introduce yourself at the start of a new rotation: “Hi, I’m Dr. X, the new intern on surgery. Please page me for any concerns on my patients.”
• Treat concerns seriously: If a nurse calls about borderline hypotension, don’t dismiss it—go see the patient and update the team.
• Thank them when they help you avoid errors or catch early deterioration.

Consultant services:

• Be concise with your consult requests:
  • “We’re consulting you for: evaluation and management of new-onset atrial fibrillation in a 72-year-old POD1 after open AAA repair.”
• Provide pertinent data when you call: vitals, key labs, imaging, comorbidities, and specific questions.

Managing Up and Managing Stress

As a prelim, you may feel pressure to “outperform” in every setting. Burnout is real, and part of excelling in clinical rotations is learning sustainable habits.

Strategies:

• Prioritize tasks: Triage your to-do list as stat, urgent-but-not-emergent, and can-wait.
• Use brief micro-breaks: Two minutes to drink water or stretch after a string of pages can prevent decision fatigue.
• Debrief difficult cases: Use peers, mentors, or wellness resources to process bad outcomes or conflicts.
• Know your limits: Escalate when you’re in over your head. Saying “I need help” early is safer—and seen as more professional—than silent struggle.

---

From Third Year Rotations to Prelim Surgery: Bridging the Gap

Your experiences during third year rotations and sub-internships (Sub-Is) shaped your initial clinical skills. In your preliminary surgery year, you’re expected to function with more autonomy and efficiency.

What Changes from Medical Student to Prelim Resident

Area	As a Clerkship Student	As a Prelim Surgery Intern
Responsibility	“Follow” a few patients	Primary provider for many patients
Orders	Suggest and discuss	Enter and enact, with appropriate oversight
Call/Overnight	Limited or supervised only	Direct involvement in cross-cover and admissions
OR Role	Usually observer/assistant	Active assistant, sometimes primary closer
Evaluations	Narrative, mainly on knowledge/attitude	High-stakes, used for letters and future matches

Recognize that your prelim surgery year is not a repeat of third year rotations—it’s the real thing, with real consequences for patient outcomes and your career trajectory.

Applying “Clinical Rotations Tips” at the Resident Level

Many familiar clerkship success tactics still apply, but they need to be dialed up:

• Read with intention: Instead of general chapter reading, focus on issues you saw that day: post-op ileus, DVT prophylaxis in trauma, management of open fractures.
• Use each case to build patterns: Every appendicitis, cholecystitis, or SBO is a chance to refine your mental algorithm.
• Log experiences and reflections: Jot down challenging cases, successful saves, and mistakes you learned from. These can later inform personal statements and interview stories.

---

Strategically Using Rotations to Shape Your Future Path

A prelim surgery year often includes rotations outside of core general surgery—ICU, vascular, trauma, surgical subspecialties, ED, and sometimes medicine or anesthesia. These are all opportunities.

If You’re Targeting Categorical Surgery

• Prioritize surgical rotations for your top performance—trauma, ICU, general surgery, vascular.
• Seek longitudinal mentorship: Ask your PD or a trusted attending to help you network with programs that might have categorical openings.
• Create a portfolio of excellence: Strong letters from surgical attendings, documented leadership, maybe a small QI or research project.

If You May Pivot to Another Specialty

• Identify rotations that intersect with your target field:
  • Anesthesia: OR time, ICU
  • Radiology: trauma, oncologic surgery
  • EM: ED time, trauma
  • PM&R: trauma, orthopedics
• Let your attendings in that field know your interest early on. Ask what they look for in residents from other backgrounds.
• Use your surgical experience as an asset: comfort with acute care, procedural skills, and working under pressure.

Evaluations and Letters: Make Them Work for You

• Ask for mid-rotation feedback: “If evaluations were written today, what would they say? What can I improve before the end?”
• Request letters soon after a strong rotation while details are fresh.
• Provide your letter writers with your updated CV, personal statement draft (if available), and a brief summary of your goals as a prelim surgeon.

These steps ensure your clinical rotations translate not just into learning, but into concrete career advancement.

---

Frequently Asked Questions (FAQ)

1. How can a prelim surgery intern stand out on busy clinical rotations?

Focus on being the most reliable and prepared person at your level. Pre-round thoroughly, know your patients’ data without prompting, anticipate team needs, and volunteer for high-yield tasks (discharges, calls to families, follow-up on critical labs). Show consistent improvement based on feedback. Being calm, organized, and dependable under pressure stands out more than trying to look impressive in isolated moments.

2. I’m overwhelmed by the workload. How do I stay afloat while still excelling?

Start each day with a prioritized task list. Tackle time-sensitive items first (stat labs, unstable patients, new consults), then notes and routine orders. Use checklists for pre-rounding and sign-out. Ask your senior early when you feel overloaded—“I have six new admissions and two discharges; can we triage what’s most important?” Efficient communication often gains you support and prevents burnout.

3. Will being a prelim (instead of categorical) hurt how attendings view me during rotations?

Most attendings and chiefs judge you by your performance, not your contract type. If you show up with the same professionalism, ownership, and growth mindset as categoricals, they will usually advocate for you just as strongly. Be transparent about your goals and ask for mentorship; many faculty have helped prelims match into categorical spots or other specialties successfully.

4. How much should I study outside of work during my prelim surgery year?

Aim for frequent, focused micro-learning rather than long cram sessions. Even 20–30 minutes most days can be powerful if it’s directly tied to cases you saw (e.g., reading about management of acute cholecystitis after admitting such a patient). Use commute time or brief breaks to review high-yield topics. When you’re very fatigued, prioritize sleep and recovery—your clinical performance and patient safety come first.

---

Excelling in clinical rotations during a preliminary surgery year is less about perfection and more about trajectory: showing that you learn quickly, own your responsibilities, communicate effectively, and function as a trusted member of the team. If you deliberately apply these strategies, your prelim year can become one of the most transformative—and career-defining—periods of your training.