Colon & Rectal Surgery

What Colon and Rectal Surgery Actually Is (Beyond the Textbook)

Colon and rectal surgery is a surgical subspecialty built around a single anatomic corridor—the large intestine, rectum, anus, and the pelvic floor structures that support them—but that corridor carries a clinical breadth that surprises most applicants. The disease mix is wide: colorectal cancer (colon and rectal, each with distinct staging logic and operative strategy), inflammatory bowel disease in all its surgical expressions, complex diverticular disease, pelvic floor dysfunction, hereditary polyposis syndromes, perianal Crohn's disease, anorectal pathology from fistula-in-ano to squamous cell carcinoma, and acute large-bowel emergencies. A mature CRS practice touches oncology, reconstructive surgery, endoscopy, multidisciplinary tumor board work, and longitudinal chronic-disease management in proportions that shift depending on setting but rarely disappear entirely.

The training model is a fellowship grafted onto general surgery: five years of general surgery residency followed by a one-year ACGME-accredited colon and rectal surgery fellowship. A small number of programs run integrated or combined pathways, but the standard pipeline produces a surgeon who is genuinely double-trained. At the fellowship level, operative autonomy arrives earlier than in most general surgery years because the case volume concentrates on a defined anatomic territory rather than spreading across the full abdomen and thorax.

Day-to-day attending practice looks like this: clinic time is heavier than in many surgical specialties because IBD patients require ongoing surgical counseling across years, surveillance colonoscopy is often surgeon-performed, and rectal cancer patients need careful preoperative staging discussions and postoperative follow-up. The OR is technically demanding—pelvic dissection for rectal cancer or proctectomy for IBD involves narrow working space, critical neurovascular structures, and decisions about sphincter preservation that carry profound quality-of-life consequences. Anorectal procedures, often dismissed as minor, require a specific tactile skill set and a willingness to engage with anatomy and examination techniques that many surgeons avoid. Endoscopy—diagnostic and therapeutic colonoscopy—is integrated into most CRS practices in a way that is not true of general surgery broadly.

What it is not: it is not a specialty for someone who wants to operate on the full abdomen without subspecialty focus, or who wants to avoid the conversation about stomas and cancer prognosis. The scope is intentionally narrow-and-deep rather than broad-and-general.

The 60-Second Gut Check: Do You Recognize Yourself Here?

The following traits appear with consistency among surgeons who find CRS genuinely satisfying rather than merely technically competent at it. Read the list as a self-identification exercise, not a credential list.

You find pelvic anatomy legitimately interesting—the nerve planes, the fascial layers, the relationship between the mesorectum and the autonomic plexuses—not just necessary to learn but worth understanding deeply.
You are comfortable with the anorectal exam and do not mentally defer it. You do not experience the examination as a burden to minimize; you use it as a diagnostic instrument.
You have noticed, during general surgery rotations, that you gravitate toward colon cases and ask questions about what the attending is doing with dissection planes rather than simply following along.
You can hold a long-term relationship with a patient across multiple admissions, operations, and years of follow-up without losing clinical focus. The IBD patient you see in clinic for the third time in eighteen months is not a drain on your attention—they are a continuity that has clinical meaning to you.
You are not avoidant of high-stakes quality-of-life conversations. Telling a patient that sphincter preservation may not be oncologically appropriate, or that a permanent ostomy is the safer reconstructive option, requires a specific communication willingness. You do not find yourself mentally rehearsing ways to defer that conversation to someone else.
You find endoscopy interesting enough to pursue skill in it rather than treating it as an obligatory procedural add-on.
You have a tolerance for—or genuine interest in—the multidisciplinary oncology environment: tumor boards, collaboration with radiation oncology and medical oncology, neoadjuvant therapy sequencing, and restaging decisions.
Complexity does not destabilize you. The patient with perianal Crohn's disease who has failed multiple medical regimens, has a prior fistula repair, and now presents with a new abscess is a problem you want to work through, not transfer.

If six or more of these feel accurate without effort, read on. If fewer than four land, the sections below will help you locate the friction point before it becomes a match-year discovery.

A Day in the Life: CRS Fellowship vs. General Surgery Residency

The comparison is useful because most applicants have lived general surgery residency and are trying to project forward into what fellowship will actually feel like.

General surgery residency (PGY-3 to PGY-5 reference): Case variety is broad and intentionally so—hepatobiliary, foregut, breast, endocrine, trauma, colorectal, hernia, all within the same rotation block or even the same day. The educational logic is exposure and breadth. Operative autonomy builds slowly because the attending is always orienting to what this resident has and hasn't seen. Call is unpredictable and the overnight admits can come from any surgical disease category. Continuity of care with individual patients is limited by the rotation structure.

CRS fellowship (PGY-6/7): The case mix narrows sharply and intentionally. A typical week involves a combination of elective colorectal cases (laparoscopic or robotic colectomy, proctectomy, IPAA, anorectal procedures), clinic (IBD follow-up, surveillance, postoperative wound and stoma checks), and colonoscopy or flexible sigmoidoscopy. Emergency coverage is colorectal-focused: large bowel obstruction, acute severe colitis, complicated diverticulitis, anastomotic leak, anorectal sepsis. Operative autonomy is characteristically higher than the late general surgery years because the fellow is the subspecialty expert in the room for most cases. The attending operates with you differently than in residency—the expectation is that you are leading the dissection and being corrected on fine points, not being walked through the basic approach.

The fellowship year is also a year of professional identity consolidation. You are already a general surgeon by training; you are now building the subspecialty layer. That identity shift changes how you interact with attendings, medical oncologists, and referring physicians. The dynamic is collegial in a way that is qualitatively different from residency hierarchy, and most fellows report that as one of the unexpected satisfactions of the year.

What does not change: the physical demands of a busy surgical service, the emotional weight of cancer patients, and the need to manage complications directly. Fellowship does not produce a protected training environment; it produces concentrated, high-autonomy training within a defined scope.

The Procedural Portfolio: What You Will and Won't Operate On

Understanding what CRS does and does not include operatively is essential before committing to the training pathway. Surprises in either direction—unexpected scope, or unexpected omissions—predict dissatisfaction.

Core procedures:

Laparoscopic and robotic right and left colectomy, sigmoid colectomy, total abdominal colectomy
Low anterior resection with colorectal or coloanal anastomosis
Abdominoperineal resection (APR) including extended and extralevator approaches
Ileal pouch-anal anastomosis (IPAA, J-pouch) for ulcerative colitis and familial polyposis
Transanal total mesorectal excision (TaTME)
Transanal minimally invasive surgery (TAMIS) and transanal excision for early rectal lesions
Pelvic exenteration (in programs with appropriate volume and multidisciplinary infrastructure)
Anorectal procedures: hemorrhoidectomy, fistula-in-ano repair (including advancement flap), LIFT procedure, fistulotomy, sphincteroplasty, lateral internal sphincterotomy, excision of pilonidal disease, repair of rectovaginal fistula
Rectopexy and pelvic floor repair for rectal prolapse and obstructed defecation
Diagnostic and therapeutic colonoscopy, flexible sigmoidoscopy, polypectomy
Stoma construction and reversal (ileostomy, colostomy, loop and end configurations)

What falls outside standard CRS scope:

Upper GI surgery: esophagectomy, gastrectomy, Whipple procedure—these belong to surgical oncology or HPB
Liver and pancreatic resection (unless in a combined surgical oncology/CRS program)
Bariatric procedures
Ventral hernia repair outside of colorectal reconstructive context (though component separation in the setting of ostomy reversal or abdominal wall reconstruction is not uncommon)
Appendectomy is within scope but is generally not a primary focus of CRS practice; most appendectomies are performed by general surgeons
Gynecologic procedures unless operating as part of a multidisciplinary pelvic exenteration team

The procedural portfolio is deep within its domain. If what you want is operative variety across the full abdomen, CRS will feel narrow. If what you want is to perform the full range of procedures within that domain at a high technical level, the depth is genuinely satisfying.

Personality Archetypes That Thrive—and Struggle—in CRS

These are composite archetypes drawn from the observable patterns in surgical training and practice. They are not types you declare; they are patterns you recognize or don't.

Archetype 1: The Anatomist-Technician

This is the surgeon who finds dissection planes intellectually interesting independent of the case. They will pause a robotic proctectomy to think carefully about the Denonvilliers fascia and its relationship to the neurovascular bundle in a way that communicates genuine curiosity rather than anxiety. They read operative atlases voluntarily. They like the tactile feedback of anorectal examination as a diagnostic skill. They often become technically excellent and are sought out for complex pelvic cases. The friction point for this archetype: they can find the longitudinal care and communication-intensive side of IBD management less engaging, and may unconsciously underinvest in the relationship dimension of their practice. Patients with chronic IBD who are not yet surgical candidates need something from their CRS surgeon beyond technical readiness, and the Anatomist-Technician has to consciously develop that capacity.

Archetype 2: The Chronic-Disease Quarterback

This surgeon is energized by coordinating care across disciplines over time. They are comfortable being the clinical anchor for a patient who is seen by gastroenterology, medical oncology, radiation oncology, and the ostomy nurse, and they find satisfaction in being the person who synthesizes those inputs into a coherent surgical plan. They are strong communicators and patients trust them with the hard conversations. The friction point: this archetype sometimes underinvests in technical mastery relative to communication skill. CRS is an operatively demanding field, and a surgeon who is organizationally excellent but not deeply invested in pushing their technical ceiling will hit a satisfaction wall when the cases get harder. The technical and relational demands are not separable in this specialty.

Archetype 3: The Oncologic Strategist

This surgeon is drawn to rectal cancer specifically—the staging algorithms, the neoadjuvant therapy sequencing, the watch-and-wait protocols, the technical demands of TME, and the tumor board environment. They find the intersection of surgical oncology principles and pelvic surgery intellectually stimulating. They are often effective in academic settings. The friction point: anorectal benign disease—hemorrhoids, fistulas, pilonidal disease, pelvic floor dysfunction—constitutes a significant portion of any CRS practice, and the Oncologic Strategist who finds this work uninteresting or beneath their attention will struggle to build a complete practice and will communicate that disengagement to trainees and patients. Benign anorectal surgery is technically demanding and clinically meaningful; it is not optional.

Lifestyle Realities: Call, Volume, and Career Geography

CRS is a surgical subspecialty and carries the call and volume expectations of that category. What is distinctive is the nature and distribution of those demands compared to general surgery broadly.

Call burden: In academic practice, CRS surgeons typically cover colorectal emergencies on a rotating basis with colleagues, which can mean one-in-four or one-in-six call patterns depending on program size. The acute overnight cases that dominate this call are large bowel obstruction, complicated diverticulitis, acute severe colitis requiring urgent colectomy, anastomotic leak, and perianal sepsis. These are high-stakes cases that often require operative intervention at night. Private practice patterns vary more widely and depend heavily on group size. A solo or small-group private CRS practice can carry disproportionate call burden; larger multispecialty surgical groups distribute it more.

Operative volume: CRS is a moderately high-volume surgical field. Case volume expectations differ between academic and community practice, but a CRS surgeon in active practice operates at a rate that generally exceeds many surgical subspecialties with narrower procedural scope. Endoscopy adds additional procedural volume. The combination is demanding in terms of physical stamina across a career.

Geographic concentration: ACGME-accredited CRS fellowship programs are not uniformly distributed across the country. Programs concentrate in academic medical centers and major metropolitan areas. This has a downstream effect on career geography: CRS attending positions in some regions are sparse, and building a CRS practice in a rural or small-market setting requires either a general surgery hybrid arrangement or a practice model designed explicitly for lower-density environments. Applicants with strong geographic constraints should map program and job market geography early. See the current program distribution data on the relevant site data pages.

Academic vs. private practice: Academic CRS practice typically involves fellowship training, resident education, research or quality-improvement activity, and a higher proportion of complex referral cases (locally advanced rectal cancer, reoperative IBD, pelvic exenteration). Private practice CRS, particularly in high-volume community settings, often involves higher procedural throughput with a larger proportion of elective benign disease and standard cancer cases. Neither is inherently more demanding, but the nature of the demand differs. Academic surgeons often cite the intellectual environment and trainee interaction as central satisfactions; private surgeons often cite autonomy, direct patient relationships, and compensation structure. These are not mutually exclusive outcomes but they require intentional career path choices.

The IBD Crucible: Are You Built for Long-Term Longitudinal Care?

Inflammatory bowel disease is not a disease you treat once and discharge. Crohn's disease and ulcerative colitis follow patients across decades, and the CRS surgeon who manages IBD will be part of that longitudinal story at multiple decision points: the first surgical consultation when medical therapy is failing, the discussion about colectomy and pouch reconstruction, the postoperative management of pouchitis and cuffitis, the reoperative case when a pouch fails, the perianal Crohn's disease that requires staged surgical management across years.

This is fundamentally different from the episodic care model that dominates most of acute and elective surgery. An IBD patient may know their CRS surgeon better than their primary care physician. That relationship is clinically valuable—a surgeon who knows a patient's pouch anatomy, their prior fistula repairs, and their disease behavior history is better positioned to make correct decisions than one encountering the record cold—but it also requires a specific kind of sustained attention that not all surgeons find energizing.

The surgeons who describe IBD management as one of the most satisfying parts of their practice consistently report that the longitudinal relationship is the reason. They find the tracking of disease trajectory, the shared decision-making over time, and the ability to intervene surgically at the right moment and then follow the patient's recovery deeply meaningful. The surgeons who find it less satisfying typically describe feeling tethered—unable to close a case and move on, perpetually managing a chronic disease that surgery can modify but not cure in Crohn's.

Before committing to CRS, ask yourself specifically whether longitudinal surgical relationships feel like an asset or a burden. Both answers are valid and informative.

Ostomy Conversations and Oncologic Prognosis: Emotional Fit Matters

Two communication demands in CRS are sufficiently distinctive and sufficiently intense that they warrant direct examination before specialty commitment.

The ostomy conversation: A significant proportion of CRS surgeons' clinical encounters involve stoma counseling—either as a preoperative necessity (this resection will require a temporary or permanent ostomy) or as a postoperative adjustment (this pouch has failed and you will need a permanent stoma). For many patients, particularly those with rectal cancer or complex IBD, the prospect of a permanent stoma is the central quality-of-life concern of their illness. The conversation is not a brief informed-consent box to check. It requires understanding what the patient's prior life looked like, what their social and occupational circumstances are, what fears they have that they haven't articulated, and what accurate expectations for life with an ostomy actually mean—which requires the surgeon to know and respect that many patients with permanent stomas describe equivalent or improved quality of life relative to their disease burden before surgery.

Surgeons who approach this conversation as a liability-management requirement—say the words, document the consent, move on—communicate that attitude to patients. Surgeons who engage it as a meaningful clinical exchange build the trust that makes postoperative adjustment easier and that sustains patients through the learning curve. The emotional labor here is not about managing your own distress; it is about investing genuine attention in a conversation that cannot be shortcut.

Oncologic prognosis conversations: Rectal cancer is a disease where the staging conversation, the treatment sequencing conversation, and eventually the recurrence conversation all fall to the CRS surgeon as primary relationship holder or as a central participant in a multidisciplinary team delivering difficult news. The surgeon who operates on a patient for rectal cancer is not handing off to medical oncology and walking away; they remain clinically present across the patient's disease course. That means they will have conversations about disease recurrence, about the limits of resection for locally advanced disease, and about palliation in the setting of unresectable disease.

This is not unique to CRS—surgical oncology and other specialties carry similar demands—but it is more concentrated in CRS than in many surgical fields because the patient relationship is often sustained rather than episodic. Applicants who have found themselves energized by difficult conversations during training—who have sought out palliative care rotations, who have asked to be present for family meetings, who have felt that these conversations are part of the work rather than a painful interruption of it—are describing a communication temperament that fits CRS well. Applicants who have consistently experienced these conversations as destabilizing or aversive should examine that honestly before choosing a field where they are unavoidable.

How CRS Compares to Adjacent Surgical Specialties

The decision between CRS and related specialties is one of the most important and most undertreated in surgical career counseling. Here is a direct comparison against the fields where the overlap is real and the confusion is common.

CRS vs. Surgical Oncology

Both involve cancer operations, multidisciplinary tumor board participation, and high-stakes prognosis conversations. The key differences: surgical oncology spans the full abdomen and sometimes beyond—liver, pancreas, stomach, soft tissue, melanoma—while CRS concentrates on the colorectal and anorectal region with greater technical depth in pelvic dissection and anorectal procedures. Surgical oncology does not include the benign anorectal disease, IBD surgery, or colonoscopy that are central to CRS practice. If your interest is specifically pelvic/colorectal cancer and you also want IBD, anorectal, and endoscopic work, CRS is the better fit. If you want hepatobiliary or upper GI oncology alongside colorectal cancer, surgical oncology provides that breadth. These are not competitive choices—they serve different appetites.

CRS vs. Minimally Invasive Surgery / Bariatric Surgery

MIS/bariatric surgery emphasizes laparoscopic and robotic technique across the upper and lower GI tract with particular focus on foregut and bariatric reconstruction. It is heavily technique-driven and the patient population skews toward metabolic disease rather than cancer or IBD. CRS also involves advanced laparoscopic and robotic technique, but the case mix is entirely different. If your interest is in advanced minimally invasive technique and you find cancer and IBD less compelling than metabolic disease and foregut reconstruction, MIS/bariatric is a better directional fit. If robotic pelvic dissection for rectal cancer is the operative image that motivates you, CRS is the correct path.

CRS vs. Urology / Gynecologic Oncology

Urologists and gynecologic oncologists also operate in the pelvis and occasionally share operative cases with CRS surgeons (pelvic exenteration, rectovaginal fistula repair, multi-organ resection for locally advanced disease). The overlap is at the procedural frontier but the primary training and practice domains are entirely distinct. Applicants who find themselves drawn to pelvic surgery broadly but uncertain whether their interest is colorectal, urologic, or gynecologic should examine specifically which disease processes and patient populations they want to follow longitudinally—that is the more reliable differentiator than operative anatomy alone.

Signs This Specialty May Not Be Your Best Fit

The following are concrete mismatch signals. They are not disqualifying character defects; they are data. Ignoring them costs years.

Consistent avoidance of the anorectal exam. If you find yourself preferring to document "deferred" or waiting for someone else to perform the digital rectal exam, that aversion will not resolve with more training. It will shape how your patients experience their care and how you experience your practice.
Odor and contamination intolerance that has not habituated. Colorectal surgery involves fecal contamination, stomal effluent, and perineal wound management. Most surgeons adapt in early training. If by late residency you still find this physically aversive in a way that affects your performance or your willingness to engage, that is a real signal about fit.
Strong preference for acute episodic care over chronic disease management. If the most satisfying clinical experiences you can identify are defined by their closure—a clean repair, a discharged patient, no ongoing relationship—CRS will chronically frustrate that preference because IBD and cancer surveillance keep patients in your orbit for years.
Disinterest in endoscopy. Colonoscopy and flexible sigmoidoscopy are not peripheral skills in CRS; they are central to the practice. A surgeon who finds endoscopy tedious or clinically uninteresting will underperform in a part of the role that is not optional.
Avoidance of quality-of-life and prognostic conversations. If you have consistently deferred difficult conversations to palliative care, social work, or other team members rather than developing your own capacity for them, and if that pattern reflects a stable preference rather than a training gap you are actively working on, CRS will put you in those conversations repeatedly and the mismatch will be apparent to patients.
Primary motivation is procedural volume without attachment to a specific patient population. CRS has strong procedural content, but the patient relationships and disease management dimensions are inseparable from the operative work. Surgeons who want high procedural volume across diverse anatomic territories without longitudinal patient obligation will find CRS confining.
Geographic inflexibility that conflicts with program and job market distribution. If the geographic region where you must practice has limited CRS program or practice infrastructure, the career path becomes structurally difficult in ways that are worth examining before fellowship application rather than after.

Signs You Are on the Right Track

These are not accomplishments to manufacture for an application. They are experiences that, if they have already occurred spontaneously, carry predictive weight.

You have asked to scrub extra colon and rectal cases during general surgery residency when it was not required. The ask was driven by genuine interest in those operations rather than CV building.
You have found yourself reading about pelvic anatomy, TME technique, or IBD surgical management outside of required preparation—because the subject held your attention on its own.
You have volunteered for or specifically sought out ostomy clinic, and found it clinically meaningful rather than administratively burdensome.
You have had a difficult conversation with an IBD or colorectal cancer patient—about a stoma, about disease recurrence, about realistic surgical limits—and come away from that conversation with the sense that it mattered and that you were capable in it, even if it was hard.
You have performed anorectal examinations with diagnostic attention and precision, and found that you are developing a clinical sense from them rather than treating them as an obstacle to imaging.
You have participated in a multidisciplinary rectal cancer tumor board and found yourself engaged in the staging and treatment sequencing logic rather than waiting for it to end.
Patients with complex surgical histories—reoperative IBD, prior failed repairs, multiple prior abdominal operations—produce clinical curiosity in you rather than avoidance.
You have performed colonoscopy during training and noticed that you want to get better at it, not just complete the required numbers.

The pattern these items share is spontaneous engagement—doing the thing when you didn't have to, finding it interesting when you could have been indifferent. That is the most reliable pre-match predictor of specialty satisfaction that exists.

Self-Assessment Checklist: Rate Your Fit Before You Commit

Score each item from 1 (does not describe me) to 3 (clearly describes me). Be honest; this is for your own use.

I find pelvic anatomy and the technical demands of rectal dissection genuinely interesting, not just technically necessary to learn.
I am comfortable performing and interpreting anorectal examinations and do not avoid them.
I want a surgical practice that includes ongoing longitudinal relationships with patients across years, including IBD and cancer surveillance.
I have sought out colorectal and anorectal cases in training beyond what was required, driven by interest rather than obligation.
I find endoscopy worth developing as a skill and can see it as a satisfying part of my procedural practice.
I am capable of and willing to hold quality-of-life conversations about stomas, oncologic prognosis, and end-of-life considerations with surgical patients.
I can function in a multidisciplinary environment—tumor boards, collaboration with gastroenterology, medical oncology, radiation oncology—without feeling that it dilutes my role.
The deep but focused procedural scope of CRS (colorectal, anorectal, pelvic floor, endoscopy) is more appealing to me than operating across a broader anatomic territory with less depth in any one region.
I have the physical and emotional stamina for a practice that involves cancer, complex chronic disease, and high-stakes surgical decision-making as routine rather than exceptional features.
I have examined the geographic realities of CRS program and job market distribution and they are compatible with my life circumstances.

Scoring guide:

25–30: Strong fit signal. The evidence supports pursuing CRS with conviction. Use the next rotation to confirm rather than to decide.
18–24: Mixed signal. Identify which items scored 1 or 2 and examine whether they reflect a training gap you can address or a stable preference mismatch. That distinction matters more than the aggregate score.
Below 18: The mismatch signals are substantial enough to warrant serious examination of adjacent specialties before proceeding. That is not a failure finding—it is the point of the exercise.

This checklist does not predict match success. It is designed to surface the information you need to make a high-quality specialty decision before you invest two to three years of application preparation and a fellowship year in a field that may not serve you well.

Your Next Step: How to Pressure-Test Your Interest This Rotation

If you are currently on a CRS rotation, general surgery service with colorectal exposure, or about to arrange an away rotation, the following tasks convert this rotation into structured evidence-gathering rather than passive exposure.

Specific questions to ask the CRS attending on rounds:

"What was the hardest decision point in this patient's surgical planning, and how did you reason through it?" — This reveals how they think about surgical strategy, not just what they did.
"How has your practice mix shifted over your career, and what part of it do you find most satisfying now?" — This gets you real longitudinal data about career trajectory in CRS rather than the idealized version given to applicants.
"What do you wish you had known about CRS before fellowship that you know now?" — This often yields the most honest information available.
"How do you approach the conversation with a patient who is facing a permanent ostomy and is resistant to it?" — Their answer tells you something about their communication investment and values.

Behaviors to observe in yourself during the rotation:

When a colon or rectal case is added to the schedule, what is your first reaction—engagement or obligation? Track this honestly across multiple cases, not just the first.
In ostomy clinic or IBD follow-up clinic, are you paying attention to the relationship dynamics and disease management logic, or are you waiting for the next operative case?
When you perform or observe anorectal examinations, are you building a diagnostic framework from what you find, or are you completing a required element?
After a difficult prognosis conversation with a patient, do you feel that the conversation was part of the clinical work you wanted to do, or does it feel like a cost of the specialty?

How to use a journal effectively:

At the end of each clinical day during the rotation, write two to three sentences in response to this prompt: "The moment today that held my attention most was _____ because _____." Do this for four to six weeks and review the pattern. If the moments that held your attention are consistently in the anorectal exam room, in the OR during pelvic dissection, in the tumor board, or in the difficult patient conversation—that is data. If the moments that held your attention are consistently outside of CRS-specific work, that is also data, and it is worth more to your career decision than any checklist score.

Specialty choice at this level is a falsifiable hypothesis. You are testing the hypothesis that CRS is the environment where your clinical identity will be most fully expressed. This rotation is your primary dataset. Collect it deliberately.