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Hand Surgery fellowship after General Surgery.

Discussion in 'Surgery and Surgical Subspecialties' started by Orange Julius, 04.22.06.

  1. Orange Julius

    Orange Julius Senior Member

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    I'm looking at the various fellowship options available to GS grads. Not making any definate choices yet, just narrowing down the list. I've come across a few people who are planning to do hand surgery after a GS residency, and I have to say, I find the idea interesting. But hand surgery is basically orthopedics isn't it? Or at very least plastics. Is it really possible to do hand as a GS trained surgeon and be competitive with orthopod or plastics hand surgeons? Are GS/hand surgeons qualified to do the same range of hand procedures? Do they recieve the same compensation? Any info would be appreciated. Thanks.
  2. Smoke This

    Smoke This Sweet cuppin' cakes!

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  3. friedtofu

    friedtofu Junior Member

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    bump! i'm also interested in this!
  4. navysurgeon

    navysurgeon Senior Member

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    GS trained hand surgeons are a rare breed.

    I think only a dozen or so GS sit for the Hand board exam each year, maybe fewer.

    The job prospects for GS trained hand surgeons is limited, because most groups looking for a hand surgeon will also be looking for a surgeon to take general ortho call.

    There are a few dedicated 'hand centers' around the country, but most are controlled by orthopods, and tend to hire orthopods.

    Perhaps you could convince an HMO to hire you to do both hand surgery and general surgery clinic and call.

    The other thing to consider is the patient population you're dealing with. A lot of hand injuries occur in uninsured patients, or Medicare patients...blue collar folks with power saws etc. Reimbursement will be a problem, especially if you're in private practice.

    I'd consider doing a vascular or onc fellowship instead.

    Just my opinion.
  5. At our county hospital, hand call is covered by Plastics and Ortho (who alternate call days).
  6. medbuck

    medbuck New Member

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    Orange Julius,
    I feel that I need to clarify a few things. First of all, Hand Surgery after General Surgery is very possible if you are very motivated in residency to learn hand and upper extremity during your general surgery years. I am a 4th year general surgery resident who fell in love with hand surgery during my plastic surgery months and have pursued a fellowship in hand surgery. Despite the misinformation you are receiving in the responses to your post, Hand surgery has become much more competitive. I just finished interviewing and have actual statistics for you, not archaic FREIDA info. So far this year, there are approximately 170 registered applicants (ortho, plastics, and general) for the hand surgery match. Last year, 135 applicants returned a rank order list for 122 spots. 111 applicants matched (18% unmatched). This is in stark contrast to 3 years ago when only 70 applied. This year's match should be even more competitive. I was not treated differently for being a general surgery resident but I do have a lot of experience in hand and upper extremity. The problem with GS residents is that we typically don't have much experience with fracture fixation. There are ways of strengthening this if you are willing to put in the extra time and are at a GS program that is flexible. Of course there are programs that only want ortho residents but those programs do mainly ortho upper extremity. Nowadays, the best fellowships incorporate all aspects of hand including ortho, plastics, and microvascular. Also, if you are trying to get a hand fellowship to strengthen your application for plastics, then you will be frowned upon. These programs want to train Hand surgeons not plastics applicants. These GS residents who are trying to write a ticket to plastics by doing a hand fellowship are easily seen through.
    I respectfully disagree with the statements that you will find no jobs in metro areas. This is simply not true. I know of many offers in big cities (Chicago, Denver, Atlanta, LA, Minneapolis, Houston, Dallas, etc.) for fellowship-trained HAND SURGEONS. I have a friend (GS trained) who is finishing her hand fellowship and got offers just about everywhere and decided on Denver. Another friend is in LA. I have not even begun my fellowship yet and have numerous opportunities. Are they less than what an ortho trained would have, sure. But there are so many jobs out there and hand surgery is evolving so much that even the ortho-trained guys have little time to do anything other than hand. Even a lot of the big ortho groups now want a 100% hand surgeon. There are a lot more than "a few hand surgery groups" in the country! The future of hand surgery is no longer ortho, plastics, or general surgeons doing hand. It is HAND SURGEONS doing hand. I also like the fact that I can focus on hand surgery and not worry about also taking call for general or ortho or plastics.
    Interestingly enough, I have listened to lectures at both the ACS meeting and ASSH meeting the last couple years regarding the future of hand surgery. Within the next 5-10 years, there will be a path out of GS similar to the 3+3 or 4+2 plastics. GS interest has dramatically increased and is pushing for this. Remember, General Surgery founded hand surgery. GS is making a serious comeback in hand surgery. Don't let other people's misinformation deter you if you are motivated and enjoy this field. Despite what Navysurgeon says, if you like the field go into it. Don't choose surgical oncology or vascular because of his (incorrect) suggestion that you won't make money. Hand surgeons are extremely well-payed and have a generally good lifestyle. It sounds like you need to speak with some hand surgeons and not people that don't know what they are talking about.
  7. Plastikos

    Plastikos

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    Interesting, there were a ton of unfilled spots regularly and then bam, competitive. Many apps are probably looking for a way to buff up their plastics applications, as hand/micro surgery seem to be the way many ppl get into academics, and while i agree that YOU may be able to see through them, i am continually amazed at how ppl like that are able to smooze up the PDs.

    Generally good lifestyle, as long as your not doing too many replants. I have never heard of hand surgeons making a ton of money, do you have any links to that effect? I know of only a couple of very well paid hand surgeons (Myles Cohen), who do mostly hand of course. I have also heard there is a lot of workers comp, etc....What is your take on that side of it?
  8. medbuck

    medbuck New Member

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    Plastikos, most hand surgeons don't do replants and when they do, it is few and far between unless you are at a place like Louisville. Hand is a good lifestyle, and they do make very good money. I don't have a website to quote on salaries, just the offers that I have personally seen and the colleagues I have worked with.
    Also, although there are more general surgeons applying for hand surgery recently to boost their plastics applications I was told at just about every interview that applications are way up for all specialties (General Surgery, ortho, and plastics). Most programs are not sure why. Even ortho has suddenly had a big rebound.
    Just like most fields, hand surgery has peaks and valleys with interest. Hand was extremely competitive in the past and then became non-competitive. Now it is changing again.
    In the end, if you like hand surgery, do it. It is a good field.
  9. Plastikos

    Plastikos

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    Personally, i like craniofacial now (about to start plastics residency), but for plastics guys it seems that Hand is one of the favored fellowships for ppl trying to get into academic plastics. I think i like hand but havent had much overall experience, though i will get my share soon. It makes sense that one wouldnt do many replants in the real world and those are mainly in tertiary centers with residency programs. This "real world" seems to be a different beast entirely.
  10. medbuck

    medbuck New Member

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    Plasticos, you are correct. Good luck to you. If you become interested in hand and choose to mainly do that, you wouldn't be disappointed. However there are many good options for plastic surgeons so you will be happy no matter what as long as you enjoy what you are doing.
  11. Orange Julius

    Orange Julius Senior Member

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    Thanks Medbuck. That's a great reply. :thumbup:
  12. Jocomama

    Jocomama Make 'em bleed!

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    I concur, Doctor!
    Medbuck is right on the money. A hand-only surgeon in Detroit suburbs is actually a DO that did a hand fellowship. He is one of the leading hand surgeons in the community, and helps train Plastic Surgeons at Wayne State.

    Medbuck; great reply!

  13. droliver

    droliver Moderator Emeritus

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    Reality check from the real world here:

    There is tremendous demand for hand surgeons & it is very easy to get a job from whatever background (GS/PRS/Ortho) and just do hand.


    The other shoe:
    The reason there is a demand is because no one wants to do it. There is a lot of ER work & night call for decreasing reimbursement and increasing liability. The fewer surgeons doing it make for even more night call among the remaining pool. I have privledges at 7 hospitals and am getting begged to cover hand call because out of 35 Plastic Surgeons in town there are 2 that do hand at all and the University here is now turning down hand trauma as their PRS/Ortho division faculty by in large no longer do hand.


    This whole thing is due in part to the establishment of the CAQ in hand surgery which set up a barrier to doing hand surgery as Surgeons in the past argued that without one you were 'less' qualified to do hand surgery and it led to fewer people doing hand in their practice. (this episode is one reason why there are not going to be any more CAQ's proposed by Orthopedics or Plastic Surgery boards -> ie. they have a way of becoming exclusionary tools). Lo and behold as reimbursement dropped there was suddenly an unattractive job with few surgeons doing it and now hospitals are in dire straights for ER coverage. This situation is not going to improve until stipends are paid for call coverage I believe.

    You can find well-paying jobs in hand, but they are a fraction of what was made in the past & are going to include a lot of ER/emergency coverage.

    As far as a short-track Hand Surgery specialty, I don't forsee that becoming a reality. You'd have to have both Orthopedic and Plastic Surgery organizations agree to "lop off" a part of their specialties to create this new field. From past experience watching CVS get tooled by cardiology with percutaneous treatments, you won't see specialties so willing to cede parts of their core competency away again. One thing I think will change everything is the eventual coming of Universal Health Care to the USA. If that happens you'd prob. see some redistribution of interest (especially in Orthopedics) away from what are the current popular insurance-based work. (BTW there is a good article in The Atlantic magazine this month on how the whole debate on universal health care is going to be decided when Wal-Mart's costs make them join with Labor to push the feds on this - good stuff!) I don't think Plastic Surgery will ever be as large a presence in hand surgery again.

    There are some short-track models in the rest of the world for hand. One of my 'fellow' Fellows in Louisville @ KKA was from Singapore & he was a product of a 3+3 hand residency there & had been sent by his chaiman to spend a year with Kelinert,et al. He was REALLY good.
  14. Yeah, hand call at the local county hospital can be rough. There are a ton of fractures (usually from fist fights), "fight bites," dislocations, AC fossa abscesses from IVDU, miscellaneous hand abscesses (including felons), fingernail infections, avulsed nails, incomplete amputations from accidents involving machinery, dog bites, flexor tenosynovitis...the list goes on and on and on.
  15. Pin-Lag-Lock

    Pin-Lag-Lock Junior Member

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    I agree 100% with droliver about the ER coverage and on call responsibilities. I was set on doing a hand fellowship but change my mind when I saw how the new (recently graduated) hand guy was getting nailed on days he was on call as well as on days he was not on call. I also recalled the experiences I had on my hand rotation where I was being nickel and dime by the ER for anything and everything with the hand which was mostly trivial stuff. There were many trips made to the ER at night, in addition, many hours spent in the ER doing procedures. It baffles me that hand is becoming so competative. I hope people are going into hand because they truly love hand and can deal with the nuisances of the specialty. Just another opinion.
  16. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    Thanks to medbuck and droliver for the update on the field of Hand Surgery. Very interesting... (unfortunately, too late for me know :( ).
  17. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    Hey KC, are you doing Hand?
  18. AstalaFP

    AstalaFP Junior Member

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    Dear Dr Oliver I am a foreign Trained General Suregon now finishing family practice here in US this year. I know places like Kleinert, Luoisville takes foreign graduates.But what could it be the possibilities of mine doing hand surgery after felllowship.
    Thank you
  19. You want to practice as a hand surgeon here in the US, or in your home country? If it's the former, you need to go through a general surgery residency here in the US, I believe.
  20. mysophobe

    mysophobe Recovering Germophobe

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    Either that, plastics or ortho.
  21. navysurgeon

    navysurgeon Senior Member

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    Medbux

    Feel free to take all the hand call you want. It's yours.

    xTNS
  22. Pilot Doc

    Pilot Doc SDN Angel Moderator Emeritus

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    Given the manpower shortage Dr. O describes, I bet he could get find a job here with fellowship only. He needs
    1) a license, which I think all states will grant to IMGs after three years of residency
    2) privileges - generally hard to find without being GS BE/BC, but people make exceptions in the right circumstances.
  23. medbuck

    medbuck New Member

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    Droliver, there is a lot more to hand surgery than call. It is too bad your experience with it has been poor. I haven't had the same experience but unfortunately if you are in the wrong place or position that can happen regardless of the specialty. In fact, I was warned off general surgery for the very same reason but ignored that b/c I liked surgery. Hand surgery does have a lot of outpatient elective procedures unlike what is being portrayed here. Like I said before, if you enjoy it, do it. And Navysurgeon, if you hate hand so much why do you keep coming back to this thread? :)*
  24. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    Medbuck, as a PRS resident I've seen the pain of hand call and the pleasure of elective hand surgery. More and more plastic surgeons and orthopods are moving away from taking hand call because of the growing reluctance of emergency physicians to take care of hand problems in the ED. Surgeons who have the CAQ are often being told that if they want privileges for elective hand surgery, they have to take hand call.

    I love hand surgery. I went into plastics because of my attraction to hand surgery. Elective hand surgery is a beautiful thing, but the pain of hand call can be unbelievable. Add in the low compensation, especially from the patients that you'll see in the ED: uninsured day-worker who lops off his fingertips in a saw, drunk guy who puts his hand in a motor, and drunk guy who got into a knife fight and nailed FDS and FDP in zone 2.

    Hand surgery is fun, but declining compensation, onerous call, and a large cohort of dirtbag patients is driving lots of people who have more profitable options away.
  25. navysurgeon

    navysurgeon Senior Member

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    Medbux,

    I don't 'hate' hand surgery. I don't even know much about the technical aspects of it, as I'm starting PRS this July. But I DO know that hand call sucks.

    In summary, I'm excited about learning hand surgery, but I have a deeply rooted, and well-cultivated hatred for the ER. Fours years as a general surgery attending has that effect on one's outlook.

    Enjoy.

    xTNS
  26. AstalaFP

    AstalaFP Junior Member

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    Why hand surgery after 4 years of general surgery experience
    Surgery is always fascinating much more prestigious
  27. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    I had seriously considered it, even used my elective time to do a Hand rotation. But in the end advice about my employability as a general surgeons doing Hand (and not wanting to do Gen surgery) led me to a Breast Fellowship. So, not unhappy, its also a good match for me, but have always loved hand anatomy and surgery.
  28. HTD

    HTD Practicing Surgeon

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    Why not take a look at the web site for the American Society for Surgery of the Hand and try some of the resources they have for people interested in hand surgery?
    www.assh.org

    This is a special community in the surgical world with three pathways of entry Ortho, GS and PRS. Very intersting. The only other area I can think of like this is Head and Neck Oncology.
  29. bigtimesmally

    bigtimesmally Member

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    why can't someone do half general surgery and half hand surgery as part of their practice just as ortho guys do? for example, have your own private practice, and build your reputation as both general and hand guy?

    Or can't someone join a general surgery group and as part of their credentials and skills, have the hand surgery fellowship which would be a bonus to the group because he/she would be accepting hand clients as well?

    Your thoughts?
  30. There's no way you could practice as a general surgeon if your training stopped midway through your PGY3 year.
  31. bigtimesmally

    bigtimesmally Member

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    Who said about stopping training? Still would have to finish the 5 year residency.
  32. navysurgeon

    navysurgeon Senior Member

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    bigtime,

    so let me make sure i get this straight:

    you're suggesting taking both Gen Surg and Hand call, as part of combined practice.

    I'm curious what annual salary you would accept as fair compensation for such a practice?

    xTNS
  33. bigtimesmally

    bigtimesmally Member

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    Obviously, I didn't think about that aspect of the issue. :idea: :scared:

    I really wouldn't know. I am just throwing out ideas because I had high interest in hand right from 3rd year of med school and want to make it a reality if possible. I know interest in hand from GS is growing, so, shouldn't there be an expansion of how practice is set up in the future.

    FYI: I know of a GS graduate with Hand fellowship who landed a $300K job in Arizona. So, it's not impossible.
  34. Member1982

    Member1982

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  35. MossPoh

    MossPoh Textures intrigue me

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    Necromancy at its finest! :p
  36. mosfet

    mosfet Senior Member

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    All the stuff about GS trained hand surgeons not finding jobs or not getting paid well may be a thing of the past. We have several chief residents in my program who just finished hand fellowships after GS training that have landed good jobs with salaries ranging in 300's. One in Texas and one is Missouri I believe. But my observation is n=3. So take it with a grain of salt. I would be interested in knowing other ppl's experiences.
  37. igap

    igap

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    Don't know a lot about the job market for hand surgery in 2010. However, if you check the statistics for last year's match, it looks pretty competitive. The overall match rate was 75%, with lots of ortho and plastics applicants not matching. I have been told that the hand match last year was the most competitive in the history of the hand match.

    Looking at the NRMP stats for the hand match last year, it looks like it is getting hard for all applicants and particularlly for general surgery applicants.

    I do know a general surgery trained person who finished up a hand fellowship last year, and that person told me that compared to the plastics and ortho trained hand people, he is having a harder time finding a good job. Some of the places wanted him to cover general surgery call as well as take hand call. Additionally, this person feels that the offers are lower for the general surgery trained people. N=1 though, so...
  38. Guile

    Guile 1K Member

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    Mysteriously this is also true for every specialty...every year. Amazing!
  39. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    As I understand it, there was a "significant uptick" in the number of Plastics applicants to Hand fellowships last year. There have been multiple conjectures as to why, but the root seems to be that people who are currently finishing Plastics are worried about the economy and see Hand as an attractive way to ride out the bad climate.
  40. Guile

    Guile 1K Member

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    How long is a hand fellowship?
  41. igap

    igap

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    Mysteriously? The hand match information is available on the NRMP web site. As far as the hand match being the most competitive ever, I really don't know. The match rate was only 75%. That seems low to me.

    The prevalent attitude in the past, in the plastics world, was that hand surgery was not a difficult match. That clearly is not the case anymore. I personally know one plastics resident, and one ortho resident who both did not match last year. They are both residents at prestigious programs, and are excellent residents. They only went to a few interviews thinking that the match would be easy. They were pretty surprised on match day.

    As far as there being an uptick in plastics applicants, I'm not sure that the data on the NRMP web site bears that out.
  42. Guile

    Guile 1K Member

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    I was more referring to the fact that it seems everyone says this about their own specialty every year.
  43. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    I looked at the link. I don't see anything that shows a breakdown of previous training for the applicants, it just breaks down the base of the programs (e.g. Indiana Hand Center is run through an Ortho group, so it is listed under Ortho and Kleinert is listed under Gen Surg)

    My comment was based on what I've heard Hand PDs saying over the past couple of years. I applied in 2008 and there were only a few Plastics guys in the match my year. I have heard that there were significantly more the year behind me. Last year (when I was a fellow), my program interviewed somewhere between 12 and 15 Plastics applicants. Several openly said that they were applying because they were worried about the job market and thought the extra credential would help them get started (which I think is very smart).
  44. droliver

    droliver Moderator Emeritus

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    Much like it's hard to be a part time microsurgeon, it's really hard to be a part time hand surgeon in terms of your practice. To offer the best hand care, you really need a dedicated set of resources (like xrays) and employees (like hand therapists). It's such a specialized service, it's gotten very hard to do in the context of a "normal" individual or small group plastic surgery practice. It's much easier incorporated into orthopedic groups as they already have most of the infrastructure in house for their other procedures. Most of the need for hand surgeons is to cover ER call in my experience, as "gentleman's hand surgery" (carpal tunnel, trigger fingers) on well insured patients seems to be well covered by orthopedic surgeons.

    Of the 30 plastic surgeons in my city (not including the University hospital whom do the obligatory usual ER hand practices), the only plastic surgeon (one of my partners) doing any elective hand cases is retiring next month. I spoke to the only other one in our call group who has hand privledges (of 12 of us ) who told me he was dropping hand privileges as all he gets are "sh*t from the ER"
  45. desimd77

    desimd77

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    This is a great thread and I felt the need to contribute. I have been on the Hand interview trail this year and it is extrememly competative. The number of general surgery applicants has gone up substantially, so has the number of plastics applicants.

    The last place I went to had nearly 35 people interviewing for 1 spot. These were for the most part plastics fellows trained at prestigous institutions. I on the other hand, am a general surgery resident from a smaller academic institution.

    We'll see what happens, but i'm not as hopeful as I was going into this. Hand surgery is very cool though and I would love to get a spot.
  46. punch

    punch

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    Please let us know what happened to your hand fellow application?
  47. Chakrabs

    Chakrabs

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    This guy did a gen-surg residency (at a community program, no less) and went on to do a hand fellowship.
  48. punch

    punch

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    How do you know that this is "that" guy? BTW how are you gearing up for your PGY1?
  49. Chakrabs

    Chakrabs

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    I was a student on the surgery service while he was the chief. I asked him where he was going for fellowship. As for me, I asked the interns at the program I matched for their advice and got a few books and will slowly read a little bit before hand. Also, just the way my schedule worked, my SubI is right now so even though its more work than the vast majority of my classmates, its good to get back into the swing of clinical medicine and take care of patients before starting residency in a few months.
  50. punch

    punch

    Joined:
    05.01.11
    Messages:
    43
    Thx and GL, you have a bigger role to play.

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