General Surgery

Schaden Freud said:

"How do surgeons face the risk of acquiring bloodborne pathogens (especially HIV, HCV) from their patients? What restrictions, official and unofficial, do HCV-positive surgeons face in practice (e.g: higher insurance premiums)?"

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Let me start by stating that I do not know any surgeons who are HIV or HCV positive so I can't answer as to the specifics restrictions one may face. But I can relate a personal anecdote.

I was doing bilateral V-Y groin advancement flaps after excision of perineal hidradenitis. (If you don't know what hidradenitis is, believe me, it should be on your short list of things you don't want to have). He was HIV and Hep B/C positive. I stuck myself really good during closure. I know that the risk of transmission is extremely low after a solid bore needle (versus hollow bore) stick, (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=28167) but I have been tested every six weeks since and I think about it almost every day. So far I'm negative and I expect to stay that way, but I did talk to a few colleagues about the consequences of testing positive.

One point of view was that I would be bound ethically to tell anyone I operated on that I was positive and to provide data about the risk of transmission. They could then make up their own minds. There was also an argument for not saying anything since it would be damn near impossible to transmit disease to a patient unless you were like the dentist many years ago who did it on purpose. The justification for the latter point of view, besides the astronomically low risk, was that we operate on people all the time without knowing their serological status and therefore are always at risk. I don't entirely agree with this, but it I'll put it out there anyway. There are some good articles here:

http://www.cmaj.ca/cgi/content/full/164/12/1715
http://www.medscape.com/viewarticle/413582

As far as what I do, I wear two pairs of gloves and I've been doing so since I was an intern (even when I operate on kids). There are microholes in the latex gloves, but the chances of having two microholes line up together over a possible break in the skin while your operating in a bloody field on a positive patient have got to be pretty small. While there's no data to support two-glove use and decreased rate of transmission, it makes me feel better. I've seen some only wear two gloves when they know that they're operating a positive patient. Unless you're used to it, you'll find that you'll be a little clumsy. I am also a lot more careful about my needles.

--M

meowkat444 said:

It seems that you are pretty involved in practice. I am applying for MSTP because I love science and want more scientific training but I am potentially interested in surgery. How do you find the PhD benefits you now? Are you still doing research in the field you studied as a grad student?

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Like you, I loved the research and could see no other way than the combined route. I didn’t know I was going to be a surgeon until I walked into an OR for the first time as a third year med student. I knew I was home. If I had wanted to be a surgeon from the beginning, would I have made the same choice? Probably.

I think going through the Ph.D. training teaches you to think scientifically, design experiments with appropriate controls, get some understanding of statistics, and most importantly, evaluate the scientific literature. The first item and the last are probably the most applicable to what I’m doing now. As a trained scientist, you really do have a different thought process when approaching problems...not necessarily better, just different. The ability to be able to read papers critically, in my opinion, is almost enough just by itself.

Now do you really need all this to do science as an M.D.? It really does depend on the science. Most of the M.D. crowd (with some very notable exceptions) does clinical research and they depend on the basic scientists to do the grunt work. The M.D.s don’t always understand the nuts and bolts, but they’re usually very good at the application. The reverse is also generally true. The combined degree people are supposed to be the bridge. So it really depends on what you want to do in your career.

I currently do not do the research I did in grad school, but I will most likely stay in academics and get some science projects going again. It was my goal to take the basic science into the clinical arena when I started all this, and while I didn’t know I would end up in plastic surgery, I’ll figure something out.

I know that there is a M.D./Ph.D. forum, and there are going to be lots of opinions on this, but you really need to find your own path. Keep an open mind and follow your heart.

--M

w166um said:

I was wondering if taking Step 2 CK in October is too late.

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I wasn't sure about this one so I enlisted the help of Plasticdraper. He relates the following:

If an applicant aced Step I, I would advise him/her to delay step 2
until the last semester after interviews have been done- no point in
risking a poor score.

For those who want to show their Step II scores to offset a poor or
mediocre Step I, I would advise them to take Step II as early as
possible so that their initial applications and thus, their initial
impressions will show their Step II. Some programs use USMLE cutoff
scores for interviews and a great Step II score may buy them an
interview. Furthermore, an applicant walking into an interview to meet
an attending may benefit from that initial impression of being "that
guy with the 262 on Step II." May as well milk that step II for as
much mileage you can get by using it to land the interview, shape the
interview, and then as a boost in the rank list session. Those
applicants who show their step II score later may only derive marginal
benefit after they've made their initial impression.

Hope this helps.

--M

owlet said:

Hi,
I'm an older nontraditional student (mid 30s with PhD) who will begin med school this fall. Will I have a harder time getting into competitive surgical residencies because of my age?

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I, like you, was also a "non-traditional" student followed by being a "non-traditional" resident and then fellow. The good news is that there are more of us than there were ten years ago, and older folks are getting residencies.

The bad news is that there is still some discrimination. When I applied to residency out of medical school, I was 39. I actually had some program directors tell me that I was too old and wouldn't make it through a surgical residency. With the advent of the 80 work week, this isn't too much of an issue anymore. Another discriminatory hurdle, and it makes sense, is that a program may consider how long it takes to train a surgeon versus how long that trainee would be expected to practice. In that regard, they may consider training someone younger because of career longevity.

During your interviews, and you will get interviews if your scores and letters are good, be prepared to discuss why you want to do surgery as an older person, why you chose this career in the first place, your career goals, etc.

And, if I may, a word about the "competitive" residencies. I believe that many of the top places (and I'm sure some might disagree) already know, for the most part, who they will be taking prior to the interview. This may include people from their lab, their med school, or a student who did an "audition" rotation and impressed the hell out of everyone. This is not to say it's impossible to get into Hopkins, but you're going to need to be at the top of your game concerning scores, letters, research, etc.

At a lot of these top programs, you won't really operate until you're senior level. That's not to say that learning the care and feeding of the surgical patient isn't important, it most certainly is, but that's all you'll be doing. Some of these places are also very trauma heavy. You don't really need to do 2,000 plus trauma cases a year (and most are non-operative) to learn how to manage these patients.

You really should ask yourself what your career goals are. If you want an academic career, then by all means try for a university program. If you just want to be a surgeon at a community or academic affiliated program, then you should look at community programs. I trained at a community program and when I left, I wasn't afraid to operate on anything. I also managed to land two academic fellowships even though I went the community route.

One final word of caution. Ph.D.s can be viewed with suspicion, especially when your a med student. We tend to ask a lot of questions and challenge authority. Please take from me and try to refrain. Just smile, do the best job you can, and it'll be over.

--M

icare4u said:

I desperately want to go try for a General Surgery residency, but I have a very bad step 1 board score - a 192. I know I'm not a candidate for a top program, but I'll go ANYWHERE! I almost wish I had failed so that I could take it again, but there is nothing I can do about that. My grades are pretty good, although nothing great. It seems that I am a weak test-taker. I'm at the end of my third year. All of my reviews in every rotation from my attendings are GREAT, always tell me they wish I would consider their program; however, my shelf exams pull my grades down. I do have honors in some of my rotations, including surgery. I am much stronger in the clinical aspect than test settings. I'm very confident that if I can work with someone, they will like me, b/c I'm going to make certain that I WORK HARDER AND DO ANYTHING I CAN DO TO MAKE IT EASIER FOR THOSE I'M WORKING WITH. If it's something I can work at and get it, I'll get it. There is just this HUGE hurdle with the tests, and I'm very discouraged at this point.

Is it pointless to pursue a general surgery residency, should I just regroup and make up my mind to go another direction? Has anyone heard of someone with that low of a step 1 score matching in General Surgery?

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I enlisted the help of the other surgery mentors and here's what we came up with:

From VandySurgeon:

I think they could match into a general surgery, but it will be tough. He/She has said that they perform clinically better than on standardized tests, so it might be beneficial for them to do an away at a program that they have a legitimate shot at matching into. I would suggest that before doing an away rotation, they consider doing the rotation at their home program. The reasoning being that it is hard to shine in a new place (heck you don't even know where the bathrooms are), but if you can impress on rounds and in the OR with your medical knowledge it makes you more memorable.

I would also advise for the applicant to take step II as soon as possible and do as well as they can.

From Plasticdraper:

I think there is some hope for this guy. If he's a US med student and he has fairly good grades, I think a categorical spot is a definite possibility and a preliminary spot all but guaranteed. It sounds like he's good clinically- I'd recommend a couple of away subI's- both to relative "safety" programs since it sounds like he just wants to match. This can include a weaker academic program and a community program. If all else fails, he can scramble into a prelim spot and parley that into a categorical spot with hard work- I've seen this scenario played out many times. I can't say for certain that I've heard of somebody matching to a categorical spot with a 192 but I know of students with high 190s that have matched into g-surg.

From Moravian:

I agree with the above. I would add that I had a suboptimal Step I (back then it was the USMLE) and it definitely hurt me for residency. It also helps to explain why I didn't get into a combined plastics program. When I took the USMLE I, I didn't really think at that time I was going to do any clinical work. The reason for this is long and involved, but suffice to say, when I decided to do surgery, I was at a disadvantage. I did everything I could to excel clinically. I also worked on my test taking skills. Standardized test are your future and you're going to need to get better at taking them.

I don't think that Plastic draper meant to imply that community programs are inferior. I trained at a community program and was very happy there. 90% of surgery goes on in community hospitals and these academic affiliated community programs generally get the same acuity, although not some of the zebras a larger university setting may see. As I've said in other posts, you need to ask yourself what your career goals are. If you want to be a well trained surgeon, you don't need to go to Hopkins to accomplish this. If you want to stay in academics, do additional fellowship training, or are just hedging your bets, then by all means stay with the university system. You may not be at Duke, but hard work goes a long way to make up for bad scores.

--M

JDovers said:

Hello there,

I was wondering if anyone could speak to, or find someone who could speak to being a trauma surgeon. I wonder about the lifestyle issues (how often is call? is it more or less time consuming than other surgical specialties?), and the work issues (ironically, I hear the job can get a little boring).

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My initial advice would be to find a trauma surgeon(s) at your school and ask their opinion.

For my part, I would say that trauma surgery has gotten more about patient care because of the non-operative managment of most cases. There has been some talk, and some implementation, of what's called an "Emergency Surgeon." This entails taking not only trauma call, but also being the on call general surgeon for ER non-trauma emergencies. This would cover appys, choles, ex-laps, etc. This concept came into being because of the concern that trauma surgeons were not operating.

There are also "trauma surgeons" who also have their own surgical practice. And there are the trauma guys who are also critical care trained that spend most of their time in the ICU. At a big center, you might see a group of two, three or four (depending on the size of the institution) that cover trauma call, take weekly turns in the ICU and still have a side practice.

There are many ways to "do" trauma, depending on the what and where. Again, you should ask you local trauma surgeon.

--M

mjbjhu said:

I'm starting first year this august and am seriously considering surgery. What is the best way to get started as a first year and to decide if surgery is right for me? Also, what kind of contacts should I be making right off the bat (research, rotations, etc)? In other words, what is the best way to get a step ahead? Where is the starting line for first year students?

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We have answered an earlier post concerning these same issues as applied to plastic surgery.

Briefly, for year one, I would recommend focusing and mastering your grades since high grades are one of the most important things you can achieve to keep yourself in the running for top spot in general surgery. I would also recommend seeking out both an academic and community surgeon and see if you can watch some cases to see what it's all about. If you're lucky, sometimes you can parley this into a clinical or basic science project which will enhance your application and culminate in great letters of recommendation. Again, scholastic excellence is the most important thing at this point and will help you do well on Step I, which is often a cutoff used by some programs.

--Moravian and Plasticdraper

gingerbreadman said:

Hi, I am going to an M2 this fall at an allopathic med school. For most of my life, I have had palmar hyperhidrosis (sweaty palms). My hands will sweat when it's not hot or during periods of non-exertion. When I wear latex gloves, my hands do sweat still. I feel I have decent to good dexterity and good eye-hand coordination. I was recently told that I may not be able to perform surgery because of my condition and this was disappointing to hear. As time progresses, I have become more interested in surgery (Ortho, ENT, Optho) and really want to be able to do what I want in the end. Is this a "game over" for me? Do you know surgeons who suffer from similar conditions? Is there anything I can do about it?

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Hyperhidrosis, as you probably know, is a pathologic condition characterized by the secretion of sweat in excess of normal physiologic needs. People usually seek medical because their daily living becomes compromised by profuse sweating that commonly affecting the axilla, palms of the hand, or soles of the feet. It affects about 1% of the population and comes in two varieties, primary and secondary.

Primary hyperhidrosis is considered idiopathic...no known cause. Secondary can be due to a variety of reasons including physiological (emotion, menopause, hot environment, exercise), endocrine (thyrotoxicosis, diabetes mellitus), drugs (antiemetics, fluoxetine, narcotic withdrawal), and various neoplasms (Hodgkin disease, intra-thoracic neoplasms, pheochromocytoma, and some central nervous system lesions).

I’m going to assume your condition is primary. The treatment options include both surgical and conservative. Topical agents usually don’t work, and surgery (gland excision, liposuction, or sympathectomy) is not really an option considering your afflicted area is your hands. Botox has recently been used as an alternative treatment. I’ve actually seen this work to some degree. You may not get complete resolution, and you’re going to need repeated injections every 6 months. You might get to the point where you won’t need injections, but no one knows for sure as the treatment is still relatively new.

I think Botox is definitely a worthwhile alternative. And, as a side note, if I would have listened to other people, I never would have been a surgeon.

Best,

--M

See PRS, Vol. 110, No. 1, page 222

Taty said:

What about D.Os interested in transplant surgery? I could not locate any D.Os who are doing transplant surgery...so my plan is to try matching in MD general surgery residency in the place that has transplant surgery fellowship and go for fellowship after the residency...is there any other way to do this or i have to stick with my initial plan?

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I'd be the first to admit that I really am at a loss when it comes to options for D.O.s and fellowships. Vandysurgeon thinks your plan is a good one to get a transplant fellowship. I would think that the one thing working in your favor is that not a lot of people want to do transplant for a living.
My surgery program didn't have transplant and we rotated for two months at another institution. I must have done a good job because they asked if I'd be interested in coming back for a fellowship (I also think that was after several beers at the local tapworks and, as noted above, there weren't many good candidates then.). A D.O. from my program landed an excellent vascular fellowship, so I know it can be done. I also think (especially given my background which I won't go into, but believe me when I tell you that it wasn't by any means traditional) that you can do just about anything if you're willing to do what it takes to get there.

Lucky for me (and you), a D.O. who is currently a general surgery resident and frequent poster to SDN agreed to help out. She thankfully supplied the following advice which is quoted below. Please address any specific questions to her (my thanks to LovelyRita and best of luck to you).

--M

LovelyRita said:

As you have probably already figured out, I'm almost positive there are no D.O. transplant fellowships available. However, last I knew, Mercy Hospital in Des Moines (D.O. surgery residency) has a transplant service/attendings who do transplants. Perhaps doing a gen surg residency there may be an avenue to pursue a transplant fellowship. You may want to call their dept. of medical education and inquire as to whether this has been done by anyone in the past.

Second, as a D.O., your chances of matching at an M.D. surgery program with a transplant fellowship are close to zero. I know this is a blanket statement, and there ARE exceptions to D.O.'s matching M.D., but it's mostly in community programs without fellowships. When I was applying I submitted an application to a local academic medical center and they would not interview me, saying, "we do not take D.O.'s because D.O.'s cannot sit for surgery boards." This is obviously false and was ignorant on their part—I pointed it out to them and they still wouldn't interview me. It's just the way it is right now. You would likely have to buddy up bigtime with a PD and score almost perfect on your step 1 as well as maybe even rotate at such a program to have a shot.

If you are going to apply strictly to M.D. programs, keep in mind that if you don't match, you will have to scramble for a position somewhere that may be a much less desirable program and/or location. I suggest you apply and interview at enough places so that you have a rank order list of at least 15-20 programs. And once again, even if you do end up at a community M.D. program, there is absolutely no guarantee you'll get a transplant fellowship.

Now, if it's in your heart, soul and blood that you want to be a transplant surgeon, you'll find a way to do it, but it will be an uphill battle all the way, on top of the uphill battle of general surgery residency in general. General surgery residency is THE hardest residency of all the specialties.

At any rate, I would suggest calling as many D.O. surgery programs as you can (if you already have not done so) and asking if any of their residency graduates have gone on to do transplant fellowship someplace, and of course to contact them. This is certainly possible, and I do not know if there are no D.O. transplant surgeons. (I'd be willing to bet that there are, but they are few in number.)

Best of luck!

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The thread "Surgery and Surgical Subspecialties" is being split into "General Surgery" and "Plastic/Aesthetic/Craniofacial. Vandysurgeon will be the mentor for the general surgery portion. Plasticdraper and I will continue to mentor the plastic surgery thread.

--Moravian

The ACS (American College of Surgeons) has placed an updated online version of the Little Red Book on their site at www.facs.org/residencysearch

For those of you that might not be familiar with this, it's a guide for medical students looking for a career in surgery.

Regards,

--Moravian