Integrated Programs and General Surgery Privileges

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Sorry for my ignorance on this topic - my lack of knowledge actually makes it difficult for me to phrase my question properly, but here goes:

In the traditional gen surge + fellowship model, you come out as a general surgeon who can also do special thing X, because you did all of your usual generally surgery training and then something extra. Do integrated plastics programs allow you to practice as a general surgeon as well, i.e., would you still get hospital privileges to do appy/lappy? Can you still sit for the gen surge boards?

I understand that probably no one would actually want to take out gallbladders after working hard to match/train in plastics (or CT, or vascular, or other such integrated specialties), but I'm curious as to how the system (in the US) handles the integrated programs.

No. Not eligible for ABS certification and not eligible for core Gen Surg privileges.

This has been mentioned before and I think it bears mentioning again. Even if you went independent and finished general surgery, it's going to be difficult if not impossible to get general surgery core privileges depending on where you want to practice. If you're going to be in some small village in Appalachia (and there's nothing wrong with that), you can probably do what you want.

However, in a reasonable sized city where there are general surgeons in practice, it's going to be politically very hard to get through credentials committee since there will either be a GS person on that committee of someone who is friends with/refers to GS.

Let's say that you were able to actually get privileges to do some GS. Now you've gone and pissed off a whole set of docs who are now never going to refer you any patients. Not a smart move for someone just getting started. Well, what if you're in Appalachia and the general surgeon there doesn't mind and actually could use the help, especially with mastectomies since there's an increase in cancer secondary to all the deregulation of businesses that pollute the environment (sorry, got a little political there...). You are now going to be doing a mastectomy followed by reconstruction and you're not going to get paid for one of them since insurance companies handle multiple CPTs by not paying for or significantly reducing reimbursements after the first code.

Originally Posted by Moravian

This has been mentioned before and I think it bears mentioning again. Even if you went independent and finished general surgery, it's going to be difficult if not impossible to get general surgery core privileges depending on where you want to practice. If you're going to be in some small village in Appalachia (and there's nothing wrong with that), you can probably do what you want.

However, in a reasonable sized city where there are general surgeons in practice, it's going to be politically very hard to get through credentials committee since there will either be a GS person on that committee of someone who is friends with/refers to GS.

Let's say that you were able to actually get privileges to do some GS. Now you've gone and pissed off a whole set of docs who are now never going to refer you any patients. Not a smart move for someone just getting started. Well, what if you're in Appalachia and the general surgeon there doesn't mind and actually could use the help, especially with mastectomies since there's an increase in cancer secondary to all the deregulation of businesses that pollute the environment (sorry, got a little political there...). You are now going to be doing a mastectomy followed by reconstruction and you're not going to get paid for one of them since insurance companies handle multiple CPTs by not paying for or significantly reducing reimbursements after the first code.

Thank you for sharing your experience with the system with us - lots of small details that are straightforward but not obvious to those of us years behind practicing!

Originally Posted by Moravian

This has been mentioned before and I think it bears mentioning again. Even if you went independent and finished general surgery, it's going to be difficult if not impossible to get general surgery core privileges depending on where you want to practice. If you're going to be in some small village in Appalachia (and there's nothing wrong with that), you can probably do what you want.

However, in a reasonable sized city where there are general surgeons in practice, it's going to be politically very hard to get through credentials committee since there will either be a GS person on that committee of someone who is friends with/refers to GS.

Let's say that you were able to actually get privileges to do some GS. Now you've gone and pissed off a whole set of docs who are now never going to refer you any patients. Not a smart move for someone just getting started. Well, what if you're in Appalachia and the general surgeon there doesn't mind and actually could use the help, especially with mastectomies since there's an increase in cancer secondary to all the deregulation of businesses that pollute the environment (sorry, got a little political there...). You are now going to be doing a mastectomy followed by reconstruction and you're not going to get paid for one of them since insurance companies handle multiple CPTs by not paying for or significantly reducing reimbursements after the first code.

Disagree that it would be hard to get privileged to do general surgery. If you have completed a general surgery residency, and you have no malpractice history or legal probems (ie. - fresh out of training) then there is no way to refuse you privileges to do general surgery. The notion that there is an all-powerful general surgeon who will refuse to give you privileges is another misconception that people with no private practice background believe. I can assure you that if you are board eligible in any field, with no malpractice history, you will be credentialed. There will be no conspiracy to keep you out. Especially general surgery... are you kidding? Another warm body for the gen surg call pool.

As far as "pissing off" general surgeons... you might tick some off, but this is not the main issue. More so is the difficulty building a practice of doing both general and plastic surgery. Do you really want to be on call for all of the general surgery problems? Do you want to be doing trauma laparotomies at 2 am? Or having a big inpatient census of bowel obstructions, abdominal pain, and enterocutaneous fistulas? There is a reason that you went on to train in plastic surgery...If you get credentialed to do general surgery, you will be vulnerable to being stuck with a lot of nasty call...

Agree with igap.

Any other field there might be some competition, but frankly another warm body to take general surgery call would be a welcome thing.

GS privileges can come in handy for such things as repairing ventral hernias (one of my PRS friends was told she couldn't do that during an abdominoplasty since it was "GS privileges" and not PRS).

Originally Posted by igap

Disagree that it would be hard to get privileged to do general surgery. If you have completed a general surgery residency, and you have no malpractice history or legal probems (ie. - fresh out of training) then there is no way to refuse you privileges to do general surgery. The notion that there is an all-powerful general surgeon who will refuse to give you privileges is another misconception that people with no private practice background believe. I can assure you that if you are board eligible in any field, with no malpractice history, you will be credentialed.

Disagree all you want. I have seen this happen. And don't misquote me. I never mentioned an all powerful general surgeon, but different institutions have their individual politics, and their individuals protecting their turf, more so now in the current environment. As I also said, you would have a lot more freedom at some places as opposed to areas with higher saturation.

Originally Posted by Winged Scapula

GS privileges can come in handy for such things as repairing ventral hernias (one of my PRS friends was told she couldn't do that during an abdominoplasty since it was "GS privileges" and not PRS).

I had the same thing happen to me when I went to remove a really big lipoma that invaded the abdominal wall lateral to the rectus. The patient had an umbilical hernia that I put on the procedure list and it got flagged by the OR. I had to call the chair of the hospital (private children's hospital) and got it approved since my core privilege list included abdominal wall reconstruction.

One thing I will agree with iGap (although it does pain me to say that) is that I won't apply for GS core privileges because I don't want to take GS call. If I wanted to be a GS, I wouldn't have spent the extra three years. But I do stand my previous statements.

Originally Posted by Moravian

I had the same thing happen to me when I went to remove a really big lipoma that invaded the abdominal wall lateral to the rectus. The patient had an umbilical hernia that I put on the procedure list and it got flagged by the OR. I had to call the chair of the hospital (private children's hospital) and got it approved since my core privilege list included abdominal wall reconstruction.

Sometimes the OR gets carried away with these things.

I had some OR bitty try and prevent me from biopsying a skin lesion on a patient's arm while I was doing her breast cancer surgery.

Bitty: "you can't do that, you only do breast."
Me: " yes that it true that I only do breast surgery but I happen to be a general surgeon with general surgery privileges at this hospital."
Bitty: "oh..." (I am fairly sure that she, being a stickler for rules and not wanting to get in trouble, called to verify that statement of mine).

One thing I will agree with iGap (although it does pain me to say that) is that I won't apply for GS core privileges because I don't want to take GS call. If I wanted to be a GS, I wouldn't have spent the extra three years. But I do stand my previous statements.

Seriously that is the most important reason. No one wants to take GS call, not even general surgeons. It sucks (which is why I don't do it either).

Originally Posted by Moravian

Disagree all you want. I have seen this happen. And don't misquote me. I never mentioned an all powerful general surgeon, but different institutions have their individual politics, and their individuals protecting their turf, more so now in the current environment. As I also said, you would have a lot more freedom at some places as opposed to areas with higher saturation.

Not to be argumentative, but you have 2 private practice surgeons saying the same thing about getting general surgery privileges. I would like to know more details of the scenarios in which you "have seen this happen", as far as board elegible/certified general surgeons getting denied GS privileges. Did these individuals have malpractice histories, or other baggage?

Also, I practice in a highly "saturated" environment and I have never heard of anyone having a clean record getting refused GS privileges.

As far as the OR questioning cases that get posted, this is a function of numnut OR staff rather than credentialing issues. These things get cleared up with a phone call to the director of surgical services, or other appropriate hospital administrator. This is not a function of credentialing, it is a function of clipboard nursing.

I imagine there are all sorts of scenarios in terms of general surgery requirements for subspecialists. Therefore I can imagine a situation such as Moravian describes although the situation here is quite a bit different.

There are at least two local hospitals that I'm aware of that require general surgery call for anyone who is general surgery trained unless you are board certified in another specialty. This obviously prevents the non-board-certified, new grads, or those trained in specialties without boards (such as surgical oncology or MIS) from operating there. It's all about having warm bodies to take general surgery call. And they're desperate for people.

Sorry to hop onto this thread and change the topic, but I wasn't sure how to start a new thread. I'm a 4th year medical student and am trying to find information on General Surgery vs. Integrated Plastic Surgery programs - i.e. average step 1 & 2 scores, grades, how important letters of rec are, etc. FREIDA has only been so helpful, as John's Hopkins has a minimum step score of 200, while a community hospital in wisconsin had a minimum step score of 240. Any good place to get information?

I'm even wondering if applying to an Integrated Plastics program will even be feasible for me since I got the national average on Step 1 and only 15 points better on step 2. Does anyone have any idea on where I could get this kind of information or strategies when it comes to applying? Thanks!!