Another specialty advice thread for surgery

[Dunkthetall]

Having trouble deciding my career path so I decided to get the wisdom of impartial strangers. I’ve been leaning toward a surgical route, but not sure which specialty. I’d enjoy something with decent clinic and would allow me to slow down a bit in my 50s and 60s or if I wanted to spend more time with my family once I have kids. The ones I’ve been thinking about are:

Ortho: this is what I came into school thinking I’d do and what my research is in. I love the personalities and have fun when I’m on trauma with them. Even bread and butter stuff like reducing fractures and lacerations are cool to me. I also love the fact that there’s a lot of fixing, with the surgeries being really cool. But I’m not particularly interested in MSK pathology. Listening to grand rounds is somewhat boring to me and I’d be doing CME or reading up on new advances to maintain competence rather than out of interest. The only thing that’s kinda interesting to me is MSK oncology. Plus, while I’m on the path to getting pubs, I still may end up needing to do a research year, which I REALLY do not want to do. Finally, while PP joints can offer a pretty stable lifestyle, ortho seems like physically taxing work, so I don’t know what I’d do in the later stages of my career if I wanted to operate less.

Vascular: The opposite of ortho. I absolutely love the pathophysiology, the mix of endo and open procedures, and the type of medical management/clinic that comes with it. I like reading about research and new advances in the field, so that’s another plus. It’s a rough residency and they work hard, but it seems easier to transition to clinic or elective vein stuff in the later stages of my career. Even being pimped wasn’t bad; I could answer most questions and what I didn’t know I enjoyed learning about. The con is that I don’t particularly enjoy the personalities. When I was with them, the residents/fellows were nice enough, but seemed dead on the inside. They, along with the OR staff, seemed constantly on edge and afraid of the attendings. For example, there was a problem in the OR and everyone seemed terrified to call in an attending. I don’t blame them, one attending savaged a resident while they were presenting, and it seems like a common occurrence. I liked hanging around two of the residents who seemed cool, funny, down to earth, etc. but otherwise I felt like I only enjoyed time with the rotating general surgery residents more. The difference between them and the vascular people was almost night and day, and I’m not sure if this is universal or just my institution. If the personalities were more like general surgery vascular might be my top option.

Gen surg: is in the middle. I like hanging with the ortho people more, but the gen surgery resident are cool and I enjoy being around them. I also enjoy the pathophysiology and will read about it or go to grand rounds for fun. Surgical oncology is the specialty I’m most interested in, especially HPB and GI. Seems to have a balance of clinic and patient interaction along with surgery. But it’s 9 years and I wouldn’t enjoy two years of research very much. I also don’t think I want to stay in academics since I’d rather see patients than do research and don’t know what community SO is like. I’m also considering colorectal surgery since I enjoy GI and I’m interested in colon cancer and IBD. Plus I think I could do clinic/scopes if wanted to slow down. Otherwise, I don’t have much experience with it and surgeries such anal prolapse are unappealing. MIS seems cool to lesser degree, and could still do some GI oncology, but I hear the job market isn’t great. I think bread and butter gen surg would be cool, but call seems awful and again I’m not sure what I’d do later on in my career if I wanted to slow down. On a final note, I only have experience with open surgery so I don’t know if I’d like laparoscopic or robotic surgery.

I’ve also considered ENT since I like the balance of surgery and clinic with diverse career options. But I’d have to do a research year at this point and I don’t think I love it enough to do so. Same for Ophthalmology, plus I don’t really like eye surgery.

---

Members don't see this ad.

 

[OnePunchBiopsy]

It sounds like you are thinking of quite a few fields.
You pick a surgical specialty based on three things:

1. The Patient Population
2. The Procedures
3. The Ability to Live with the Complications of your Procedures

The patient population:
Kids, Adults, Geriatrics/Palliative, Healthy, Cancer, Trauma, or all of the above? Do you like seeing patients primarily from the ER, inpatient, or as clinic referrals?

The Procedures:
Open vs. endoscopic vs. robotic vs. fluoroscopic (vascular). Outpatient surgeries or procedures that require admission and rounding? Emergency life-saving cases or elective cases planned weeks in advance, or combo cases involving multiple teams? This is the hardest one to find out as a medical student since you are less likely to be hands on in the OR.

The complications:
Can you live with yourself if you spend hours on a life saving operation only for a patient to lose their life or limb? How about if you do an elective procedure with a great outcome but the patient hates how their scar looks? How about if you do an elective knee replacement that gets infected and the patient goes from limping to not walking at all?

Notice none of these factors involve how you get along with the people in each field within your program. A lot of residents make the mistake of assuming that because they like hanging out with the people in one field means that field is for them. The vascular surgeons at my gen surg program were super cool (chill, drove nice cars, etc.), but they had a kush gig and vascular surgery can be much more emergent and long hours based on your practice location. Don't get caught up amongst the trees and miss the forrest.

In regards to your opening statement "I’d enjoy something with decent clinic and would allow me to slow down a bit in my 50s and 60s or if I wanted to spend more time with my family once I have kids," based on the specialties you've listed, here are the negative aspects of these fields as I've seen them (based on 6 years of general surgery and now in plastics fellowship).

Ortho:
-Don't work at a trauma center if you want to ever slow down or spend time with your kids. Traumas traumas traumas, soft tissue infections, etc all get punted to you if gen surg or plastics refuse to deal with them. Every bone except the facial bones and cranium is your domain, and the larger your domain, the more phone calls you get. If wanting to focus on family, you could try to join or establish an elective practice focusing on shoulder/knee/hand.

Vascular:
-If an artery gets clogged you have 4 hours to surgically unclog it before the patient has permanent limb damage. If a surgeon doing a lap inguinal hernia repair cuts through the femoral vessels, you are consulted to evaluate and fix intraoperatively. Vascular is a high acuity specialty that treats patients from claudication to above the knee amputation. A vascular surgeon once told me he regretted entering the field because it took him away from his kids. All old vascular surgeons in their 50 and 60's open up outpatient vein practices, but also have to compete with dermatologists, plastic surgeons, and every dentist with a laser willing to zap skin veins for cash pay.

Gen Surg:
-You are the internal medicine of surgery. Very rarely can you say "no" to a consultation (unless it's a gross miscall). General surgeons who also do trauma are shifting towards a shift work model in private practices because you get a lot of phone calls. Even if you do a fellowship and try to become a "dumb hernia surgeon," or "dumb gallbladder surgeon," you cannot escape general surgery call unless you are a subspecialist at a large and niche academic center (i.e., hepatobiliary surgical oncologist at M.D. Anderson).


Don't pick your field based on what you want at the final destination, pick it based on how you want to live your life every day.
Best of luck.

 

[ACSurgeon]

It sounds like you are thinking of quite a few fields.
You pick a surgical specialty based on three things:

1. The Patient Population
2. The Procedures
3. The Ability to Live with the Complications of your Procedures

The patient population:
Kids, Adults, Geriatrics/Palliative, Healthy, Cancer, Trauma, or all of the above? Do you like seeing patients primarily from the ER, inpatient, or as clinic referrals?

The Procedures:
Open vs. endoscopic vs. robotic vs. fluoroscopic (vascular). Outpatient surgeries or procedures that require admission and rounding? Emergency life-saving cases or elective cases planned weeks in advance, or combo cases involving multiple teams? This is the hardest one to find out as a medical student since you are less likely to be hands on in the OR.

The complications:
Can you live with yourself if you spend hours on a life saving operation only for a patient to lose their life or limb? How about if you do an elective procedure with a great outcome but the patient hates how their scar looks? How about if you do an elective knee replacement that gets infected and the patient goes from limping to not walking at all?

Notice none of these factors involve how you get along with the people in each field within your program. A lot of residents make the mistake of assuming that because they like hanging out with the people in one field means that field is for them. The vascular surgeons at my gen surg program were super cool (chill, drove nice cars, etc.), but they had a kush gig and vascular surgery can be much more emergent and long hours based on your practice location. Don't get caught up amongst the trees and miss the forrest.

In regards to your opening statement "I’d enjoy something with decent clinic and would allow me to slow down a bit in my 50s and 60s or if I wanted to spend more time with my family once I have kids," based on the specialties you've listed, here are the negative aspects of these fields as I've seen them (based on 6 years of general surgery and now in plastics fellowship).

Ortho:
-Don't work at a trauma center if you want to ever slow down or spend time with your kids. Traumas traumas traumas, soft tissue infections, etc all get punted to you if gen surg or plastics refuse to deal with them. Every bone except the facial bones and cranium is your domain, and the larger your domain, the more phone calls you get. If wanting to focus on family, you could try to join or establish an elective practice focusing on shoulder/knee/hand.

Vascular:
-If an artery gets clogged you have 4 hours to surgically unclog it before the patient has permanent limb damage. If a surgeon doing a lap inguinal hernia repair cuts through the femoral vessels, you are consulted to evaluate and fix intraoperatively. Vascular is a high acuity specialty that treats patients from claudication to above the knee amputation. A vascular surgeon once told me he regretted entering the field because it took him away from his kids. All old vascular surgeons in their 50 and 60's open up outpatient vein practices, but also have to compete with dermatologists, plastic surgeons, and every dentist with a laser willing to zap skin veins for cash pay.

Gen Surg:
-You are the internal medicine of surgery. Very rarely can you say "no" to a consultation (unless it's a gross miscall). General surgeons who also do trauma are shifting towards a shift work model in private practices because you get a lot of phone calls. Even if you do a fellowship and try to become a "dumb hernia surgeon," or "dumb gallbladder surgeon," you cannot escape general surgery call unless you are a subspecialist at a large and niche academic center (i.e., hepatobiliary surgical oncologist at M.D. Anderson).


Don't pick your field based on what you want at the final destination, pick it based on how you want to live your life every day.
Best of luck.

Re: general surgery. I’ll just say more hospitals much smaller than “huge academic centers” now have acute care surgeons and the specialized hernia/bariatric/cancer surgeons don’t take general surgery call. Even if you did, it could be a low frequency or low intensity depending on your setup. Finally- general surgeons can absolutely refer to higher level of care, whether at their own hospital to a more specialized surgeon, or a tertiary care hospital.

I went through training thinking I’m gonna have an intense career for 30 years. My acute care gig is 1/4 call, 1/4 backup and 2/4 off (with option for icu time in my case). It’s hard to know what the job market will look like when you’re done. If you do something you actually enjoy, you’ll probably be able to make it such that you still have a good balance. That might mean less money, a fellowship, working at a smaller or larger hospital etc but it should be doable and physicians these days value work-life balance even in surgical fields.

 

[pazzer2]

I left general surgery residency for the same reasons mentioned above. With enough ICU experience, you could also transition into a shift-based ICU doc.

The call schedule is what really destroys your social life. As a surgeon you'll almost certainly need hospital admitting privileges. In return the hospitals will demand you to take call. The exception are those who operate entirely at surgi-centers.

 

[Dunkthetall]

It sounds like you are thinking of quite a few fields.
You pick a surgical specialty based on three things:

1. The Patient Population
2. The Procedures
3. The Ability to Live with the Complications of your Procedures

The patient population:
Kids, Adults, Geriatrics/Palliative, Healthy, Cancer, Trauma, or all of the above? Do you like seeing patients primarily from the ER, inpatient, or as clinic referrals?

The Procedures:
Open vs. endoscopic vs. robotic vs. fluoroscopic (vascular). Outpatient surgeries or procedures that require admission and rounding? Emergency life-saving cases or elective cases planned weeks in advance, or combo cases involving multiple teams? This is the hardest one to find out as a medical student since you are less likely to be hands on in the OR.

The complications:
Can you live with yourself if you spend hours on a life saving operation only for a patient to lose their life or limb? How about if you do an elective procedure with a great outcome but the patient hates how their scar looks? How about if you do an elective knee replacement that gets infected and the patient goes from limping to not walking at all?

Notice none of these factors involve how you get along with the people in each field within your program. A lot of residents make the mistake of assuming that because they like hanging out with the people in one field means that field is for them. The vascular surgeons at my gen surg program were super cool (chill, drove nice cars, etc.), but they had a kush gig and vascular surgery can be much more emergent and long hours based on your practice location. Don't get caught up amongst the trees and miss the forrest.

In regards to your opening statement "I’d enjoy something with decent clinic and would allow me to slow down a bit in my 50s and 60s or if I wanted to spend more time with my family once I have kids," based on the specialties you've listed, here are the negative aspects of these fields as I've seen them (based on 6 years of general surgery and now in plastics fellowship).

Ortho:
-Don't work at a trauma center if you want to ever slow down or spend time with your kids. Traumas traumas traumas, soft tissue infections, etc all get punted to you if gen surg or plastics refuse to deal with them. Every bone except the facial bones and cranium is your domain, and the larger your domain, the more phone calls you get. If wanting to focus on family, you could try to join or establish an elective practice focusing on shoulder/knee/hand.

Vascular:
-If an artery gets clogged you have 4 hours to surgically unclog it before the patient has permanent limb damage. If a surgeon doing a lap inguinal hernia repair cuts through the femoral vessels, you are consulted to evaluate and fix intraoperatively. Vascular is a high acuity specialty that treats patients from claudication to above the knee amputation. A vascular surgeon once told me he regretted entering the field because it took him away from his kids. All old vascular surgeons in their 50 and 60's open up outpatient vein practices, but also have to compete with dermatologists, plastic surgeons, and every dentist with a laser willing to zap skin veins for cash pay.

Gen Surg:
-You are the internal medicine of surgery. Very rarely can you say "no" to a consultation (unless it's a gross miscall). General surgeons who also do trauma are shifting towards a shift work model in private practices because you get a lot of phone calls. Even if you do a fellowship and try to become a "dumb hernia surgeon," or "dumb gallbladder surgeon," you cannot escape general surgery call unless you are a subspecialist at a large and niche academic center (i.e., hepatobiliary surgical oncologist at M.D. Anderson).


Don't pick your field based on what you want at the final destination, pick it based on how you want to live your life every day.
Best of luck.

Really good perspective, thank you. Especially about getting along with my peers. I’m starting to question how much I’d love ortho if I didn’t love the people in it. But my main concern is a toxic work environment where everyone is fearful. I’m cool with my attendings/mentors being hard on me because they genuinely want me to improve. And I can live with them tearing me a new one so that I won’t make a mistake twice. I just want to avoid an environment where people always seem ready to explode, even at the slightest provocation.

I suppose I’d love to see a little of each patient population, but I’m particularly drawn toward cancer patients and clinical referrals.

For procedures, I prefer open but that might be due to the fact that open was the first surgery I got to see/participate in. I don’t have much experience with lap/robotic outside of watching videos; I can’t say I’d love it yet, but I’m pretty sure I’d enjoy them more than the procedures I’d do in the IM and anesthesia specialties. Fluoro is fine, but if I did that, I’d like to balance it with open, which is why I think I liked vascular.

As for complications: I can live with bad ones as long as I’m not the one actively causing them, especially when it comes to inherently risky operations. If I did everything right to save a patient, but they lost their life or limb, I’d be sad but could live with it. Same if a limb got infected; it would suck but can live with it as long as it wasn’t due my mistake. However, the operation going well and the patient hating something like a scar is definitely something that would take its toll on me.

For ortho, how many of them keep operating into their 60s? I saw “older” doctors in vascular, but the only attending in ortho who’s older than middle-age seems to be primarily doing research. I don’t know if that’s coincidence or the productive of being at a teaching/academic hospital.

Ahh yeah, I forgot about competition in vascular. I’m hoping to set up shop in more rural or suburban areas with less competition, but this specialty looks scarier and scarier when it comes to starting a family.

For gen surg, and any specialty, I suppose call and consults don’t bother me too much. I’m more worried about something less than Q4 and frequently having to operate in the middle of the night. My most ideal setup would be an average of 60 hours a week, Q5 call, and actually having to come in to operate once every couple of months or less. And not at all past 50.

Thank you again for the reply.

 

[Dunkthetall]

Re: general surgery. I’ll just say more hospitals much smaller than “huge academic centers” now have acute care surgeons and the specialized hernia/bariatric/cancer surgeons don’t take general surgery call. Even if you did, it could be a low frequency or low intensity depending on your setup. Finally- general surgeons can absolutely refer to higher level of care, whether at their own hospital to a more specialized surgeon, or a tertiary care hospital.

I went through training thinking I’m gonna have an intense career for 30 years. My acute care gig is 1/4 call, 1/4 backup and 2/4 off (with option for icu time in my case). It’s hard to know what the job market will look like when you’re done. If you do something you actually enjoy, you’ll probably be able to make it such that you still have a good balance. That might mean less money, a fellowship, working at a smaller or larger hospital etc but it should be doable and physicians these days value work-life balance even in surgical fields.

That’s good to know. I’m okay with less money for the most part. The only hard no in terms of location is metro areas, and I’d like to avoid a permanent job where research is mandatory. As a MIS or cancer surgeon, how difficult it is to minimize call straight out of fellowship? Thank you for your time.