Surgical Specialty Characteristics

[UCI]

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

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[bc65]

What surgical specialties still practice mostly open cases (vs. laproscopic)?

Please clarify your goal. Is it to never do laparoscopic surgery? Or to do little? Why?

You might always have to do some, but it also depends on what you mean by a "surgery " specialty. Ophthalmology doesn't do laparoscopic surgery, I think. Nor neurosurgery, except maybe for pituitary surgery, if you consider that laparoscopic. Maybe those guys could chime in. There's little to none in plastic surgery, depending on your practice area, except maybe if you do endoscopic carpal tunnels ( not everyone does them that way ) or endoscopic brow lifts ( many don't believe in that operation either ) or are harvesting bowel or omentum for a microscopic free-flap procedure ( very rare, and few would be doing those).

Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?

Lots of specialties are mostly outpatient, but you still have to care for your patients if they do get admitted for one reason or another. It's not painful when they are your patients, since you did the surgery and will want to see how they are doing. Residency is different from the real world.

Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

If you get a job with a large hospital/HMO environment it's possible to have more of a shift work mentality, where the person on call at night for your specialty will take your patient back to the OR if they need to go back at night. That attitude seems more prevalent these days.

 

[mcloaf]

Please do not go into surgery if you don't want to round on your patients and you plan to consider your job shift work. That's an incredible disservice to people who trust you cut them open.

 

[pd1112]

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

If you're trying to meet all 3 of those at once, the only specialties that might be in the ballpark are ENT/Ophtho/OMFS (not exactly open cases), elective-only Plastics, Ortho Hand, Ortho Foot&Ankle (if purposely try to make career similar to Podiatry), and Podiatry (lolz). I guess you could do Urology and refuse to do any cases other than vasectomies and circumcisions.

Ortho Hand is probably the best match IMO.

 

[pulmoblast]

Scrub nurse ?
No laparoscopy, no rounds, shift work


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[Psai]

Who's going to take care of your patients after your operation? Not gonna happen.

 

[SurgeDO]

derm w/ mohs fellowship

 

[Goro]

Why did you go into Medicine if you don't want to deal with patients?

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

 

[pacman2018]

Why did you go into Medicine if you don't want to deal with patients?

 

[UCI]

Hello,

I ask these questions because I don't have mentors in medicine and I was hoping to learn more about what might exist. Thanks for those with informational replies.

In regards to everyone else, please stop trolling, you're not helping anyone.

 

[bc65]

To all those criticizing OP: I agree that surgeons should take care of their own patients and their problems, regardless of who's on call that night. However, that attitude is not universal among many otherwise conscientious surgeons in their 40's or younger. It's a product of the 80 hour and less work week, and the 24 hour shift limit. It's not how I think, but this change may not be an altogether bad thing.

 

[mcloaf]

Hello,

I ask these questions because I don't have mentors in medicine and I was hoping to learn more about what might exist. Thanks for those with informational replies.

In regards to everyone else, please stop trolling, you're not helping anyone.

Nobody in this thread is trolling. Sorry you didn't get the answers you wanted to hear.

 

[Psai]

To all those criticizing OP: I agree that surgeons should take care of their own patients and their problems, regardless of who's on call that night. However, that attitude is not universal among many otherwise conscientious surgeons in their 40's or younger. It's a product of the 80 hour and less work week, and the 24 hour shift limit. It's not how I think, but this change may not be an altogether bad thing.

I can't think of a single surgical resident who works less than 80 a week

 

[bc65]

I can't think of a single surgical resident who works less than 80 a week

I was referring to residents in general.

But sure, my heart goes out to those surgery residents doing 80 or 90 hours a week.

For the record, when I was a resident, that would have been my short week, which I considered almost like a vacation. One week a month I was only on two weeknights, and I would get the weekend off. That would be about 85 -90 hours ( 12-14 hours a day plus two nights on call. My long week would include being on call two weeknights, plus the weekend i.e. Sat am until evening rounds on Monday, around 7 or 8 pm. So, 60 hours straight in the hospital ( averaging about 3-4 hours sleep a night) Over 130 hours, a week, at least , not counting the following Monday.

Now, get off my lawn!

 

[Psai]

I was referring to residents in general.

But sure, my heart goes out to those surgery residents doing 80 or 90 hours a week.

For the record, when I was a resident, that would have been my short week, which I considered almost like a vacation. One week a month I was only on two weeknights, and I would get the weekend off. That would be about 85 -90 hours ( 12-14 hours a day plus two nights on call. My long week would include being on call two weeknights, plus the weekend i.e. Sat am until evening rounds on Monday, around 7 or 8 pm. So, 60 hours straight in the hospital ( averaging about 3-4 hours sleep a night) Over 130 hours, a week, at least , not counting the following Monday.

Now, get off my lawn!

And I'm sure you were up and at em every single hour with absolutely no rest in between.

 

[lymphocyte]

.

 

[bc65]

And I'm sure you were up and at em every single hour with absolutely no rest in between.

Reading comprehension is not your strong suit, is it? I was pretty clear. I averaged 3-4 hours of sleep on call.
Yes, on weekend days, after rounding on 40-50 patients, and writing notes, and changing dressings, if I didn't get called to the ER or a floor consult, and before the scheduled admissions started rolling in, I might have an hour or two when it was quiet. But that didn't happen very often.

It was actually much harder to be on call then. There was no outpatient surgery. In addition to taking care of all the sick patients, everyone having surgery had to be admitted, so we would have to do H&Ps on 3-10 patients. Each of those patients had to have an EKG and CXR, cbc, 6+12, even if they were 20 yo. There was no central computer, so we had to track down every lab slip by hand and check it and get it into the chart. We had to have the CXR read by radiology, but also have the hard copy in hand for the OR. If the K was off ( half of them would be a little low) we had to run in exta K and repeat the labs. If a lab was missing, we had to re-draw it. We drew the labs ourselves to make sure it was done, and done quickly. If the CXR was missing ( every night some were) we had to take the pt down ourselves and repeat it. If the EKG looked funny, we had to track down a cardiology consult. If any lab wasn't right, a private patient ( or the chiefs case) would be delayed or cancelled, ( anesthesia would do anything possible to cancel a case and go home early ) so getting all of this right was essential. ( Today, all this is out patient, it's all on the computer, and we don't even get the labs or cxr or ekg on most patients ). This is in addition to all the sick patients you have to take care of now. All the patients that go home today as outpts stayed in house, so they needed post op checks, and often had to have post op labs checked. There was a much much lower threshold for blood transfusion then, so there were lots of CBC checks and lots of transfusions to order and monitor.

All the above in addition to the work residents have to do today: seeing ER consults, traumas, floor consults, and actually taking care of the sick patients.

But you go ahead and keep telling yourself how hard you have it.

 

[hurtem&healem]

So, back to the OPs questions... As for tackling all three, would trauma surgery approach this (outside of "getting stuck" while performing a longer surgery)?

I'm personally less concerned with #'s 2& 3, but I am very curious what specialties are doing the most open surgeries, and more importantly for myself, will in all likelihood continue to be doing so for the foreseeable future?

 

[bc65]

So, back to the OPs questions... As for tackling all three, would trauma surgery approach this (outside of "getting stuck" while performing a longer surgery)?

Seriously, it's silly to talk about this now. Wait until you have done a surgery rotation in your third year of med school.

But, surgeons should round on their patients and they should be available to manage complications.

Many surgery specialties today allow for surgeons to have most of their cases be simple and outpatient, minimizing rounding (except perhaps for neurosurgery and cardiac surgery, for example)

Why do you care about laparoscopic surgery?

 

[ProfMD]

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

How about ophthalmology? Surgeries are "open," patients go home the same day, if they do get admitted, they get admitted to someone else's service. Most stuff is elective and done during the day.

For the most part, however, surgeons round on patients and the trend is toward less invasive techniques.

If you are part of a group with partners you trust, you can turn over after-hours care of your patients to whichever of them is on call that day or weekend.

 

[hurtem&healem]

Seriously, it's silly to talk about this now. Wait until you have done a surgery rotation in your third year of med school.

I get that. It's totally out of general curiosity for me at this point. I'm not trying to plan my career here. That said, am I wrong to think that trauma surgery somewhat fits OP's three criteria. I understand they can put in extremely long hours in the OR (so not necessarily "quick turnaround"), but would they then be relieved and someone else do their rounds?

Why do you care about laparoscopic surgery?

To put it simply, I think open surgeries are "cooler" in the same way I prefer a recurve bow to a compound bow. The modern technology is amazing, it's safer, and it leads to less overall suffering, but there's something to be admired about the classic ways of doing things.
Also, as I was getting at in the last part of my question, I'm curious about how many/what kind of surgeries will necessarily continue to be of the more invasive variety.

Again, I'm in this forum for edutainment, not career counseling

 

[bc65]

I'm in this forum for edutainment, not career counseling

Fair enough, although it's meant for the latter and not the former.

Trauma surgery is just surgery, and I could be wrong here, but I think very few surgeons do only trauma. Most will have a regular practice of elective cases and will do some trauma because they cover the ER. If you do only trauma you are likely in academics, and my guess is that will mean that you will still do some elective cases as well. I think regardless, you will have times when you want to come in for complications.

I once came in during a vacation to re-operate on a patient ( I was only 2 hours away at the time). So, even if you're not "on", you will likely come in on occasion.

Lots of cases can't be done closed and still have to be open. What's cool, IMHO, is doing them both ways. But you really can't pick and choose, nor should you want to, or worry about that . It's a trivial non-issue.

Once you're an attending you will like to make rounds. You will want to see your patients. It's only as a student and resident that it's a burden, because you have a huge list of 10-30 patients to see that you didn't operate on. If you operated on them, seeing them is important and interesting and (almost) enjoyable. But in any case you might have residents or a PA to make rounds for you regardless of specialty. You will still go see the patient anyway.

 

[StrongIslandDoc]

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

Anatomic & Microscopic Pathology.
Pathologist in the OR doing frozen section Bx while the surgeon waits for your word to either fully resect, get the margins, close, etc.
Open case. If its laparoscopic you wouldn't be doing the driving. No patient to round on. Go home at 6, see you at 9 tomorrow.

 

[giantswing]

Hello, questions for those with surgical specialty knowledge

What surgical specialties still practice mostly open cases (vs. laproscopic)?
Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

Thanks!

P.S. I tried to search threads for these answers, but couldn't suitable ones.

Hand via ortho or plastics. Open but itty bitty surgery, most pts are same day or you're not primary, and cush hours, minus call which, if its hand trauma only, you'll never have to go in emergently.

 

[cabergoline2]

If you get a job with a large hospital/HMO environment it's possible to have more of a shift work mentality, where the person on call at night for your specialty will take your patient back to the OR if they need to go back at night. That attitude seems more prevalent these days.

I am curious about the patient outcomes of this kind of a practice .. And frankly speaking a bit scary..A whipple is done on a monday morning...thursday night some bilious fluid is observed from the drain and the patients abdomen appears distended...bowel sounds which could be heard in the morning can no longer be heard...And the guy who operated this in the morning is not on call..so the guy who is on shift opens up the patient gain ,without knowing what went on intra-operatively the first time...Is it how bad ,things are today in some HMO's ? or am I quoting an unrealistically extreme example ?

 

[ProfMD]

I am curious about the patient outcomes of this kind of a practice .. And frankly speaking a bit scary..A whipple is done on a monday morning...thursday night some bilious fluid is observed from the drain and the patients abdomen appears distended...bowel sounds which could be heard in the morning can no longer be heard...And the guy who operated this in the morning is not on call..so the guy who is on shift opens up the patient gain ,without knowing what went on intra-operatively the first time...Is it how bad ,things are today in some HMO's ? or am I quoting an unrealistically extreme example ?

I can only speak from my own experience - an academic practice with three surgeons in my subspecialty.

Most of the stuff that keeps us busy on-call are new patients that come in through the ED. The times we have take-backs for our inpatients are few. If we have a complex surgical patient, we sign out to each other staff-to-staff and don't just rely on communication via the residents. If the on-call person has a question, we call the surgeon who did the initial procedure. That person may come in even if not on-call.

Works out well for us and our patients.

 

[bc65]

I am curious about the patient outcomes of this kind of a practice .. And frankly speaking a bit scary..A whipple is done on a monday morning...thursday night some bilious fluid is observed from the drain and the patients abdomen appears distended...bowel sounds which could be heard in the morning can no longer be heard...And the guy who operated this in the morning is not on call..so the guy who is on shift opens up the patient gain ,without knowing what went on intra-operatively the first time...Is it how bad ,things are today in some HMO's ? or am I quoting an unrealistically extreme example ?

The short answer is that it's always that way, everywhere, to some extent. So, first let me give you the scenario that I had in mind.

In private practice, I get a referral from a doc I know for right lower quadrant pain, pt in the ER. I get the call at 4pm, while I"m in the OR or in the office. I see the pt. as soon as I'm free, at 5:30 pm. I order a CT scan, maybe I decide to watch them overnight. Early the next morning, I decide to do an appendectomy, which I do at 7 am. Maybe I end up being an hour late to my office.

Possible Group practice or HMO or academic practice
( it will vary depending on the system, the department, the group ):

Patient is in the ER. Consult goes in at 4pm. Seen immediately by the doctor who's on call, who evaluates the pt, and orders a CT scan. They sign the pt out to the overnight doctor who's on call at 5 pm. That doctor checks labs, CT, examines the pt. Decides to continue watching. At 7 am, the surgeon tells the next doc that this pt needs to go to the OR. That doc examines the pt, reviews the labs, agrees, and takes the pt to the OR at 7:45 am in the reserved OR time that is there waiting for the surgeon on call to do the urgent ( but not emergency) cases.

Now, the way I trained, if I admitted the pt, I should follow them until I either operated or send them home. However, that leaves me tired, interferes with my office schedule, messes up my OR schedule, and puts all sorts of pressures on me. However, it's my patient, and I should follow and make the decision.

Scenario #2: No one seems to be completely in charge, but this system has the advantage of: a surgeon devoted entirely to taking care of the emergent patients, always being rested, and multiple second opinions. Also, no one feeling pressure to go ahead and do the surgery now so they don't get called back in the middle of the night.

==============

In your example, sure, the guy on call will probably let the operating surgeon what's going on. The truth is, anyone can go in and do the second procedure. It doesn't matter too much that the surgeon changes. Ideally the first guy would do it, but as ProfMD described, you talk on the phone if possible, and sometimes he comes in, sometimes just describes anything important or unusual, and the second guy does it. Even under the "old" way, people go on vacation, or were up all night the night before, and just are not available for the second surgery.

So, I was referring more to the appendectomy scenario than the Whipple.

I hope that helps.

NOTE: This has nothing to do with HMOs or not HMO. It has to do with group practice arrangements. Some HMOs hospitals might have one doctor in a small specialty on all the time. Private practices might have large groups with strict call schedules.

Another example: A couple of decades ago, if you had an OB, they delivered you baby, no matter when you had it. Today, women understand that if they have the baby on the wrong day or time, a partner will do the delivery. That's how it is, and it's probably safer the way we do it now.

 

[tiedyeddog]

I can't think of a single surgical resident who works less than 80 a week

I would say at my institution plenty of the GS, ortho, urology, and ENT residents are sub80 plenty weeks. There are just a few rotations, like trauma, thoracics, or transplant where they go over consistently.


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[Psai]

Reading comprehension is not your strong suit, is it? I was pretty clear. I averaged 3-4 hours of sleep on call.
Yes, on weekend days, after rounding on 40-50 patients, and writing notes, and changing dressings, if I didn't get called to the ER or a floor consult, and before the scheduled admissions started rolling in, I might have an hour or two when it was quiet. But that didn't happen very often.

It was actually much harder to be on call then. There was no outpatient surgery. In addition to taking care of all the sick patients, everyone having surgery had to be admitted, so we would have to do H&Ps on 3-10 patients. Each of those patients had to have an EKG and CXR, cbc, 6+12, even if they were 20 yo. There was no central computer, so we had to track down every lab slip by hand and check it and get it into the chart. We had to have the CXR read by radiology, but also have the hard copy in hand for the OR. If the K was off ( half of them would be a little low) we had to run in exta K and repeat the labs. If a lab was missing, we had to re-draw it. We drew the labs ourselves to make sure it was done, and done quickly. If the CXR was missing ( every night some were) we had to take the pt down ourselves and repeat it. If the EKG looked funny, we had to track down a cardiology consult. If any lab wasn't right, a private patient ( or the chiefs case) would be delayed or cancelled, ( anesthesia would do anything possible to cancel a case and go home early ) so getting all of this right was essential. ( Today, all this is out patient, it's all on the computer, and we don't even get the labs or cxr or ekg on most patients ). This is in addition to all the sick patients you have to take care of now. All the patients that go home today as outpts stayed in house, so they needed post op checks, and often had to have post op labs checked. There was a much much lower threshold for blood transfusion then, so there were lots of CBC checks and lots of transfusions to order and monitor.

All the above in addition to the work residents have to do today: seeing ER consults, traumas, floor consults, and actually taking care of the sick patients.

But you go ahead and keep telling yourself how hard you have it.

Having to see all those otherwise healthy patients sounds real bad

 

[pd1112]

Hand via ortho or plastics. Open but itty bitty surgery, most pts are same day or you're not primary, and cush hours, minus call which, if its hand trauma only, you'll never have to go in emergently.

??? There might be more emergent hand cases than any other bone/joint/region in the body.

 

[Smurfette]

??? There might be more emergent hand cases than any other bone/joint/region in the body.

Actually, most of the hand stuff can wait (other than amputations). Severed tendons can be repaired later, and there is collateral circulation to help maintain perfusion. Most hand stuff is sent out the door with instructions to call the ortho/plastics office in the AM. I'm sure others with more hand training can weigh in on this.

 

[pd1112]

Actually, most of the hand stuff can wait (other than amputations). Severed tendons can be repaired later, and there is collateral circulation to help maintain perfusion. Most hand stuff is sent out the door with instructions to call the ortho/plastics office in the AM. I'm sure others with more hand training can weigh in on this.

Yeah I was exaggerating but if you're on call for hand, you're absolutely going in for amputations and deep hand infections, and I imagine those are both fairly common everywhere.

 

[giantswing]

??? There might be more emergent hand cases than any other bone/joint/region in the body.

Nothing that you'd be called in at night for that generally couldn't wait till morning, except for maybe replants which not all do.

 

[giantswing]

Yeah I was exaggerating but if you're on call for hand, you're absolutely going in for amputations and deep hand infections, and I imagine those are both fairly common everywhere.

No, and no.

 

[pd1112]

No, and no.

So you're letting those sit overnight?

 

[ProfMD]

So you're letting those sit overnight?

I think @giantswing's point was that these are not common.

I work at a place with a pretty busy hand service and I don't think I have heard of our hand surgeons coming in for either of these, at least not recently.

I am sure there are places that do these more frequently, but not anywhere I have worked.

Also, not all hand surgeons do replants.

 

[pd1112]

I think @giantswing's point was that these are not common.

I work at a place with a pretty busy hand service and I don't think I have heard of our hand surgeons coming in for either of these, at least not recently.

I am sure there are places that do these more frequently, but not anywhere I have worked.

Also, not all hand surgeons do replants.

I see. I must have had an atypical experience, so the "never go in emergently" seemed surprising.

 

[akwho]

Hand is the busiest ortho service at my county trauma center residency. Our team had 6 OR's running at the same time last week. Hand pus, fireworks, GSW's, replants, and revasc's. Lot's of it is emergent unless your private practice doing carpal tunnels.

 

[pd1112]

Hand is the busiest ortho service at my county trauma center residency. Our team had 6 OR's running at the same time last week. Hand pus, fireworks, GSW's, replants, and revasc's. Lot's of it is emergent unless your private practice doing carpal tunnels.

Sounds more like my experience.

 

[bc65]

I agree that a hand surgeon taking ER call will have a lot of emergencies, as described above.

If you have a purely elective practice, you will rarely if ever have to come in at night.

Note that the same would be true for almost any specialty. If you're a general surgeon doing purely elective breast surgery or thyroids or hernias, you won't be getting called in for anything either.

It is more a function of the kind of practice you have than the specialty you practice. You can have an elective neurosurgery practice as well.

 

[chirurgeon]

> What surgical specialties still practice mostly open cases (vs. laproscopic)?
> Are there specialties that don't round on patients (maybe a specialty with a quicker turnaround of patients)?
> Are there any shift-work environments where you can go home and not worry about patients (except when you are on call)?

One specialty that is still all open is burn surgery - I have yet to see the case report of the laparoscopic axillary scar contracture release! Gotta love the heat though - my OR is sometimes up to 110oF.

With regards to environments, it totally depends on what type of practice you join. In my current practice, I share call with 3 other partners and we divvy up the month such that we take 1 in 4 weekend call and will typically cover 4-6 weekdays/month.