Family Medicine (particularly rural) vs General Surgery

[apoptoaster]

Hey,
I was trying to search for a discussion about this in the forum, and I know the two specialties are very different, but I was wondering if anyone (particularly FM residents or grads) had difficulty deciding between family medicine and surgery. To be more specific about why I ask - I've been heavily leaning toward family medicine for a long time, and I have aspirations to practice full-scope family medicine in a rural setting (btw, I'm a 3rd year med student). I scheduled surgery toward the end of the year largely because I've never thought of myself as someone who would like surgery, and I had really low expectations for it. I've been surprised to find that I enjoy it a lot more than I thought I would, and the environment isn't as hostile as I expected it would be.

Anyway, I know there are vast differences between the specialties, but I guess what I like about both is that they are both very broad (it seems like general surgeons do a lot of different things and have to know a lot more medicine than I thought they would). I'm still about 80-90% certain that I'll end up doing rural FP, and I understand that this is a personal decision that I'll ultimately have to make on my own, but I just wanted to see if anyone else who ended up doing family medicine was temporarily enticed by general surgery and if the small amount of surgery you do in residency and the procedures that you can do in practice are indeed enough to scratch any itch you had for surgery, while still allowing you to enjoy the continuity of outpatient medicine, the variety, the versatility, and the other things that are awesome about family medicine. Any thoughts? Thanks so much for sharing!

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[VA Hopeful Dr]

To paraphrase some of the surgeons on this board...

If you can't imagine being happy in your job as a physician without being in the OR, then surgery might be for you. If you think you could go the rest of your career without being in the OR, then surgery is definitely not for you.

 

[styphon]

I work in a rural area, and all of our surgeons are GS board certified. In the innercity we did have family med attendings who focused on Colonoscopys and EGDs. I also had an attending who had extensive surgical experience when he was in Africa on multiple medical missions.

It would also depend on how you work/who employs you. If you own the practice, you set the rules. If you are employed by a hospital or organization (Federal, state, private) they may decide your scope of practice.

 

[iswitched]

What do you like about general surgery? I started in a surg subspecialty and switched to family medicine. Generalizing here, but people focused on lifestyle aspects of medicine seem to be the ones who most often draw a significant distinction between surgery and medicine. When compared to all other careers in life, they vary remarkably little from one another.

General surgery in a rural setting can be genuinely "general" where you may end up routinely working on most objects between the diaphragm and pelvic floor, simple vascular, plastics, hand, thoracic, and ortho. Not so much in the big city where people tend to choose specialists for everything because they can (e.g. colorectal guys for a hemorrhoidectomy). A general surgeon anywhere should be generally adept at many aspects of critical care medicine, so this is sort of cool if that's your thing. Bottom line, if you do general surgery in a rural setting you can be a generalist.

I think a bit too much emphasis is made on "rural" family medicine. If you have the acumen and your patient's trust then you can practice 'wide scope' FM in an urban center just as much as your rural colleague. I would argue that going through a rural program doesn't alone increase the likelihood that you can be a good rural family physician*. Paying attention during med school and residency, in addition to taking initiative at every point in your career from med school on, will make you a more capable physician no matter where you practice. As with the general surgeon, in the city setting the family doc's patients have specialist options. But arguably unlike the general surgeon, the capable city family doc has a fighting chance of doing full scope family medicine (save working in a closed ICU, etc). Understand that in a city setting managed care/employed family docs may have there scope limited for other reasons (as mentioned in the previous reply).
*IMO only, a very small percentage of programs (like the one in Washington, ?Tacoma) truly seem to force residents to be "rural capable" and seem to select real go-getters. This in contrast to many so-called rural programs that are no more than a ho-hum residency that happens to be located closer to a farm-and-feed store.

Regarding FM procedures: I don't do OB. In FM residency c-sections (the cutting/sewing part) certainly "scratched the itch" as did vasectomies just a bit. The rest of the dinky cutting and sewing FM procedures for me are are a nice way to feel blue collar again for a few moments, but they only last a few moments. Complicated lacs nowadays is about as good as it gets.

 

[apoptoaster]

Thanks to all of you for your thoughts and perspectives. iswitched, to answer your question, I guess what is cool to me about general surgery is their potential scope of practice, although, as some have pointed out above, that is often not as broad in practice as it is on their training. Of course, that is what I also love about FP. Also, you make a good point. I probably make the mistake of equating rural with wide scope practice. I think I care more about being able to train and practice broadly than I do about training and practicing in a rural area (although my roots are rural and I'll likely end up in a rural area), and it's nice to hear that there are FPs that practice broad-scope in larger cities as well.
iswitched, any pointers on how to tell if an FM residency program is adequately rigourous? Thanks.

 

[MJB]

I'd be interested in why iswitched did indeed switch.

That said, I strongly considered surgery and surgical subspecialties (even OB as I loved robotic surgery). What made me decide to go for family is a multitude of things, but mostly it was the lifestyle I can enjoy as an FP doing outpatient medicine and the continuity of care.

I had a surgeon (GS) tell me that unless I simply CANNOT IMAGINE DOING ANYTHING ELSE IN THE WORLD, DO NOT GO INTO GS. I saw and listened to him over the course of months. He was generally happy, but his point was that unless you literally could not live without being in the OR, you shouldn't do it because of all the negatives.

One night, while mowing the lawn, I figured out I could do medicine, take care of patients...and keep my hands busy (I love procedures), by doing office procedures and doing things like gardening, woodworking, cooking, etc...and live a likely much happier life.
My kids also have had a HUGE impact on the decisions I've made. I don't think I could have chosen better. I will have a comfortable living, I mostly enjoy my job. I am pretty confident I'll never get bored (as I likely would have as a specialist), and I will have my nights and weekends to myself...and more importantly, my family.

There is wise poster here who calls FM the "ultimate lifestyle specialty". I think he's right.

 

[MJB]

As for the scope of GS's....this is one thing that would be very appealing to me...to be THE DOCTOR in town...meaning, you could do primary care, and if they needed surgery, you had it. Unfortunately, I don't think that's possible anymore for many, many reasons. I would love to do a "fellowship" to be able to do some surgery as a FM, but don't see that happening..ever. Doing the occasional appy, GB, Port, colonoscopy, surgical abscess, etc...would be AWESOME to me. But, I can live without it...the trade off is worth it to me. Not to mention the 3 yr vs. 5 yr residency.

 

[cabinbuilder]

As for the scope of GS's....this is one thing that would be very appealing to me...to be THE DOCTOR in town...meaning, you could do primary care, and if they needed surgery, you had it. Unfortunately, I don't think that's possible anymore for many, many reasons. I would love to do a "fellowship" to be able to do some surgery as a FM, but don't see that happening..ever. Doing the occasional appy, GB, Port, colonoscopy, surgical abscess, etc...would be AWESOME to me. But, I can live without it...the trade off is worth it to me. Not to mention the 3 yr vs. 5 yr residency.

While this is all good in theory, just because you have the skills to do a surgery, if you are in a rural place it doesn't mean you will have the personnel after the fact to take care of the patient. I have been in many rural (and frontier) areas where I may have had a surgeon there but I did not have anesthesia, or ICU, or a nursing staff that was trained to take care of post surgical patients or do conscious sedation. Heck, I've had to medvac patients in DKA to the nearest hospital with an ICU because I had nurses who were only clinic trained and had NO IDEA how to take care of that type of patient. I can have all the skills in the world but in the rural parts of the country you may not have the support staff to be safe for the patient. That's just reality.

 

[YoungestBrother]

What do you like about general surgery? I started in a surg subspecialty and switched to family medicine. Generalizing here, but people focused on lifestyle aspects of medicine seem to be the ones who most often draw a significant distinction between surgery and medicine. When compared to all other careers in life, they vary remarkably little from one another.

Regarding FM procedures: I don't do OB. In FM residency c-sections (the cutting/sewing part) certainly "scratched the itch" as did vasectomies just a bit. The rest of the dinky cutting and sewing FM procedures for me are are a nice way to feel blue collar again for a few moments, but they only last a few moments. Complicated lacs nowadays is about as good as it gets.

So, having had experience with both specialties, do you think that you could have switched later in your career? I'm interested in surgery, but I imagine that it's a tough gig to keep at for 30+ years. I've worked in a family med clinic for three years now, and I like the idea of doing this kind of work as a kind of pre-retirement. Do you think that's possible?

 

[Rowdy Burns]

*IMO only, a very small percentage of programs (like the one in Washington, ?Tacoma) truly seem to force residents to be "rural capable" and seem to select real go-getters. This in contrast to many so-called rural programs that are no more than a ho-hum residency that happens to be located closer to a farm-and-feed store.

You have not seen many programs in the South if this is the way you feel. There are numerous programs in the South that train physicians for broad-scope rural practice.

 

[mandmsandmoreofthem]

Has anyone heard of people doing Surgery residency's after Family Medicine careers? It seems that the advice I get from surgeons is do whatever else you can possibly do, and unless you just can't stand being out of the OR then do surgery. I don't think I am that interested in surgery right now, but if I caught a serious itch later would it be possible? Thanks!

 

[cabinbuilder]

Has anyone heard of people doing Surgery residency's after Family Medicine careers? It seems that the advice I get from surgeons is do whatever else you can possibly do, and unless you just can't stand being out of the OR then do surgery. I don't think I am that interested in surgery right now, but if I caught a serious itch later would it be possible? Thanks!

I have a general surgeon friend who did FP (20+ years ago) first because he didn't match into surgery initially then worked to get in later. Not sure how that would work these days with how residency is funded now. You likely would not be paid as a resident for the second time around.

 

[addy]

What do you like about general surgery? I started in a surg subspecialty and switched to family medicine. Generalizing here, but people focused on lifestyle aspects of medicine seem to be the ones who most often draw a significant distinction between surgery and medicine. When compared to all other careers in life, they vary remarkably little from one another.

General surgery in a rural setting can be genuinely "general" where you may end up routinely working on most objects between the diaphragm and pelvic floor, simple vascular, plastics, hand, thoracic, and ortho. Not so much in the big city where people tend to choose specialists for everything because they can (e.g. colorectal guys for a hemorrhoidectomy). A general surgeon anywhere should be generally adept at many aspects of critical care medicine, so this is sort of cool if that's your thing. Bottom line, if you do general surgery in a rural setting you can be a generalist.

I think a bit too much emphasis is made on "rural" family medicine. If you have the acumen and your patient's trust then you can practice 'wide scope' FM in an urban center just as much as your rural colleague. I would argue that going through a rural program doesn't alone increase the likelihood that you can be a good rural family physician*. Paying attention during med school and residency, in addition to taking initiative at every point in your career from med school on, will make you a more capable physician no matter where you practice. As with the general surgeon, in the city setting the family doc's patients have specialist options. But arguably unlike the general surgeon, the capable city family doc has a fighting chance of doing full scope family medicine (save working in a closed ICU, etc). Understand that in a city setting managed care/employed family docs may have there scope limited for other reasons (as mentioned in the previous reply).
*IMO only, a very small percentage of programs (like the one in Washington, ?Tacoma) truly seem to force residents to be "rural capable" and seem to select real go-getters. This in contrast to many so-called rural programs that are no more than a ho-hum residency that happens to be located closer to a farm-and-feed store.

Regarding FM procedures: I don't do OB. In FM residency c-sections (the cutting/sewing part) certainly "scratched the itch" as did vasectomies just a bit. The rest of the dinky cutting and sewing FM procedures for me are are a nice way to feel blue collar again for a few moments, but they only last a few moments. Complicated lacs nowadays is about as good as it gets.

If you ever end up finding the name of that program, I'd love to know!

 

[sazerac]

If you ever end up finding the name of that program, I'd love to know!

Probably thinking of Providence Family Medicine, based in Spokane but located in Colville, WA. http://washington.providence.org/sh...mily-medicine-residency/rural-training-track/

 

[apoptoaster]

Just wanted to say thanks to everyone for your thoughts. With your help and the help of a 2 month rotation in surgery, it's much easier to see all the reasons why I would be much happier as an FP than a surgeon.

 

[apoptoaster]

If you ever end up finding the name of that program, I'd love to know!

It looks like iswitched was referring to the Tacoma Family Medicine program in Tacoma Wasthington. I've heard good things about this program on several sdn forums, so it seems to match the poster's description.
http://www.multicare.org/home/tacoma-family-medicine-3