Guts and Butts

3,909. That is the total number of pages in the following surgical textbooks: Corman’s Colon and Rectal Surgery (1,584 pages), The ASCRS Textbook of Colon and Rectal Surgery (1,361 pages), and Gordon and Nivatvong’s Principles and Practice of Surgery for the Colon, Rectum, and Anus (Fourth Edition) (964 pages). As you can imagine, that is a lot of material devoted to  five feet of “tubing” starting at the ileocecal valve (end of the small intestine) and ending at the anal margin (skin of the buttocks). I have read every page. That’s nearly 4,000 pages of “guts and butts”.

Why did you pick this specialty? That is the question that colorectal surgeons get asked daily. Despite fighting colon cancer, Crohn’s disease, and many other common surgical problems, colorectal surgery remains misunderstood by the lay public. For those in healthcare, however, colorectal surgery is recognized as a crucial subspecialty at the forefront of evidence-based care. At the time this writing, the Holy See is recovering from surgery for a diverticular stricture. You never know when you might need a colorectal surgeon: just ask the Pope.

Colorectal surgery is a small community. With only 50 “fellows” trained per year, it is a competitive field attracting excellent graduates from general surgery residency programs. Like many hurdles in medical education, passing a difficult multiple choice exam is required to become board-certified in this specialty.  Unlike communities with a larger pool of test takers, internal medicine mints 8,300 new residents per year, the small size of this specialty precludes the existence of online question banks. This can create a difficult situation for surgical fellows preparing for their subspecialty exams: the technique that worked in the past (using online question banks) is not available in small subspecialties where question repositories do not exist.

How should examinees prepare for a multiple choice exam if question banks are not available? The answer is simple: become a test writer. You need to create your own questions. How is this accomplished? The first step, reading critically, is discussed HERE.  Once critical reading becomes second-nature, the next step is as simple as it is effective: read multiple textbooks. The “checks and balances” inherent in utilizing several available sources will super-charge your multiple choice exam efforts.

Most medical and surgical specialties have a textbook that is considered the primary text. If you are serious about becoming an expert in your field, you must read this textbook cover-to-cover. (Author’s note: detailed recommendations for how to annotate your textbook for maximum retention will be shared in a future blog post.) In addition to a primary textbook, most specialties also have competing texts that cover the same material. There is plenty of ego and prestige (not to mention revenue) involved in writing a surgical textbook. For these reasons, most specialties have multiple textbooks vying for preeminence in their field.

My advice is to read at least two of your specialty’s primary textbooks in their entirety. What you will quickly learn is that most of the material is repeated but presented in a slightly different way. Reviewing material twice, especially when presented differently, is a tremendously effective way to learn. Adult learners need repetition. Similarly, concepts that are presented with figures, tables, and graphs in multiple primary textbooks are undoubtedly important. This “repetition signaling” aids test takers in the key task of thinking like a question writer. If a concept shows up frequently in high-quality sources you must know it cold. These are the topics from which questions should, and will, be created. Knowing this allows test takers to create their own question banks, even if their specialty is too small for such an online resource to exist. This approach allows you to master any subject. Even guts and butts.

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