What procedures could a GS realistically do after 5 years of training?

[Surgeon D.O.]

PGY-1 more than halfway through intern year. We get into the OR quite a bit at my program even at the junior level. At this time in my very early career, I think I am going to purse community / somewhat rural general surgery practice. I really would like to work outside strictly the abdomen as a general surgeon. My question is how feasible, REALISTIC and safe is this with 5 years of general surgery training?

Head and Neck / Endocrine: Thyroids. Parathyroids? Anything else fair game in this region?

Thoracic: Not sure what’s fair game here for a general guy. Any esophageal work? Hiatal? Nissen? Anything with the lung? VATS?

Breast: all mostly fair game?

GI / Abdomen: The bread and butter. Basically, all fair game minus the complex hepatobiliary stuff.

EGDs. Possible to get cert in ERCP?

Colorectal: colectomy, hemorrhoids, pilonidal, fistula, c-scope

GU: vasectomy? TURP??? C-sections?

Vascular: Ports. Amputations? AV fistula? Heard of general guys do some bypass and carotids, not sure how realistic this is and how comfortable one would be without extra vascular training.

Skin/Soft tissue: lumps, bumps, melanoma, squamous and basal. Carpal tunnel release? Ganglion cyst?

Misc. c-lines and c-tubes needed. Wound care?

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[ThoracicGuy]

One question is can it be done, which it can if you have the right training and/or mentor at your practice after residency. Should you is maybe a better question. Also, will a hospital allow you credentials for these things you wish to do.

If you have a reasonable General Surgery residency program, you should be able to do a thyroid/parathyroid. Esophagus, maybe, but not sure you'd want to do much more than maybe a nissen. I wouldn't recommend a vats lobectomy as only a general surgeon. Breast should be no problem. GI/Abdomen should be no problem as mentioned. EGD/Colonoscopy is doable, but ERCP is probably harder to get.

I don't think you'd be looking at much GU type stuff. C-sections are something that is not uncommon for a rural surgeon to assist with or do, so having a good mentor would be helpful there.

Ports are no problem and amputations are reasonable. AVF can be done, depending on your experience and mentors. Not sure you'd want to do much bypass or carotids, though.

Lumps and bumps should be fine, though carpal tunnel release may be something that ortho might do at a rural place.

Central lines and chest tubes as well as wound care are all fair game as a rural guy.

 

[DoctwoB]

Surgery is surgery. You can train a general surgeon to do almost anything, but the question is where is the training coming from if not your faculty in residency?

On the GU side, you would definitely need to go out of your way in training to get skills. Never seen a gen surg resident do more then a month on urology, usually as an intern. No way you have the scope skills to do my intervention beyond maybe scoping in a foley. Your open and lap skills are much more transferable.

Vasectomy is doable, ditto hydrocele/spermatocele but again you'd have to go out of your way to get
some exposure/practice, maybe spending some months or so on research time or something. Radical nephrectomy would be fine, but never seen a general surgeon do a partial.

Some of the most useful Uro skills for a rural surgeon are managing the urgent issues. Detorsing a testicle. draining a priapism. Getting a foley in no one else can. Putting in an SP tube. All easily learnable by any surgeon given proper exposure, but you'd have to plan and fight to get that exposure during residency, especially since these things happen to the on call resident at 2 AM, not in a scheduled fashion.

 

[Surgeon D.O.]

Thanks for the replies.

I suppose what has me scratching my head is why i don't see this broad scope of practice as much and if there is something I'm missing in terms of my potential goals.

It seems that the general guys I've worked with so far want nothing outside the abdomen. If they do, they pursue fellowship to focus on just that area/region and then want nothing to do with general/ the abdomen.

 

[LucidSplash]

Thanks for the replies.

I suppose what has me scratching my head is why i don't see this broad scope of practice as much and if there is something I'm missing in terms of my potential goals.

It seems that the general guys I've worked with so far want nothing outside the abdomen. If they do, they pursue fellowship to focus on just that area/region and then want nothing to do with general/ the abdomen.

Because it depends partially on where you train and partially on where you work after training.

Not every general surgery training program trains residents in a way that expects them to go into general surgery practice. Most of the academic programs expect you to do a fellowship. At such programs, the focus isn’t training you to be competent at procedures like thyroids or Nissens. So not every general surgery resident graduates feeling confident in doing non-abdominal work.

After training, you will go work somewhere and it may depend on the local referral patterns if you get enough referrals for certain procedures or if the workflow is established and other non-general surgeons get those referrals. If there’s an endocrine surgeon nearby, they may get all the thyroid consults. Some places are too close to a bigger town or city and general surgeons will generally not get referrals in those places if someone with subspecialty training is close enough. You have to be reasonably rural, I would say at least 1 hour or more, to build a truly broad rural general surgery practice. Even at 1 hour out, a lot of people will want to go to the big city and see the subspecialty surgeon and the PCPs may want to refer them there. It can take a lot of time and work and proving yourself to change referral patterns and even then it may not work out that you can get those patients. The farther out you go, the more desperate people get and willing to send to general surgery who is closer rather than subspecialty surgeon.

Then there’s the factor that you need to do a certain number of cases on an ongoing basis to maintain your comfort level. I wouldn’t want someone to do my thyroid who only did a couple a year. I’m technically board certified in general surgery, and I trained at a place where 40% of residents go into general practice and while the faculty was happy to support whatever your goals were, everyone graduated prepared to be a general surgeon after graduation or you didn’t graduate. But I haven’t taken out an appendix or gallbladder in 7 years because I do vascular. I could probably still do it if there was a zombie apocalypse or something and all the general surgeons got eaten, but in a non apocalyptic situation you should go to someone who does that all the time. Also I don’t want to be asked to take general surgery call so I never even applied for privileges for those things. I found I still knew how to do a trach once late at night when there was an emergency and no other surgeons were around, but I wouldn’t plan to do them regularly. 🤷🏼‍♀️

Then there’s self selection. Maybe your general attendings don’t like non abdominal/hernia work. Maybe their practices are busy enough they don’t need to do those cases if someone else does them or they don’t like doing them.

A million factors in why a general surgeon might do some procedures but not others.

 

[cpants]

Surgery is surgery. You can train a general surgeon to do almost anything, but the question is where is the training coming from if not your faculty in residency?

On the GU side, you would definitely need to go out of your way in training to get skills. Never seen a gen surg resident do more then a month on urology, usually as an intern. No way you have the scope skills to do my intervention beyond maybe scoping in a foley. Your open and lap skills are much more transferable.

Vasectomy is doable, ditto hydrocele/spermatocele but again you'd have to go out of your way to get
some exposure/practice, maybe spending some months or so on research time or something. Radical nephrectomy would be fine, but never seen a general surgeon do a partial.

Some of the most useful Uro skills for a rural surgeon are managing the urgent issues. Detorsing a testicle. draining a priapism. Getting a foley in no one else can. Putting in an SP tube. All easily learnable by any surgeon given proper exposure, but you'd have to plan and fight to get that exposure during residency, especially since these things happen to the on call resident at 2 AM, not in a scheduled fashion.

Echo above. I don't think you will be able to do endoscopic urology cases (ie. TURP, stone work) without a lot of extra technical training. Hydroceles, circumcisions, vasectomies, orchiectomy---could probably pick up without too much difficulty. I'm sure you could do a radical nephrectomy or c-section too, but just because you CAN do a thing, doesn't mean that you should.

 

[mikeGR]

As others noted, you can learn to do any of the above (some harder, some easier), but I cannot imagine any scenario outside of a 3rd world country where a general surgeon should be doing all these. In the US, I suppose if you're the only surgeon within a hundred miles radius with no specialists (incl urology or ob/gyn). I can understand the appeal of being able to do everything (esp as an eager intern), but the truth is that the more you specialize, the better a job you do at your specialty (and worse at everything else). And if there's a vascular surgeon in your city, they will prob do a better job with vascular cases (same with other specialties too).

I will say that there are still general surgeons out there who take pride in doing everything (some colleagues in my state are "experts" in all surgeries, including esophagectomies, pancreatectomies, vascular bypasses, plastic surgery, bariatrics, hernias, etc, per their websites) but this is phasing out as the older surgeons retire and there is increasing focus in the quality of care.

 

[Apollyon]

As others noted, you can learn to do any of the above (some harder, some easier), but I cannot imagine any scenario outside of a 3rd world country where a general surgeon should be doing all these. In the US, I suppose if you're the only surgeon within a hundred miles radius with no specialists (incl urology or ob/gyn). I can understand the appeal of being able to do everything (esp as an eager intern), but the truth is that the more you specialize, the better a job you do at your specialty (and worse at everything else). And if there's a vascular surgeon in your city, they will prob do a better job with vascular cases (same with other specialties too).

I will say that there are still general surgeons out there who take pride in doing everything (some colleagues in my state are "experts" in all surgeries, including esophagectomies, pancreatectomies, vascular bypasses, plastic surgery, bariatrics, hernias, etc, per their websites) but this is phasing out as the older surgeons retire and there is increasing focus in the quality of care.

Sometimes locations can be strange bedfellows. I worked in Hawai'i for 3 years (EM), 2009-2012. There was a CT surgeon there that still went below the diaphragm (which was something I'd heard ad nauseam before - once you go CT, you are done with below). My boss told me of something that occurred before I got there, so, around 2010 or so. She had a pt with vag bleeding she couldn't stop. Got the runaround from the big shop (no capacity, etc, whatever). She was almost to the point of this CT guy to do a hysterectomy (and he's not old - middle aged, but not old), and he was ready to scrub, when she finally got someone to accept a transfer. This was on O'ahu. Crazy times.

 

[Smurfette]

PGY-1 more than halfway through intern year. We get into the OR quite a bit at my program even at the junior level. At this time in my very early career, I think I am going to purse community / somewhat rural general surgery practice. I really would like to work outside strictly the abdomen as a general surgeon. My question is how feasible, REALISTIC and safe is this with 5 years of general surgery training?

Head and Neck / Endocrine: Thyroids. Parathyroids? Anything else fair game in this region?

Thoracic: Not sure what’s fair game here for a general guy. Any esophageal work? Hiatal? Nissen? Anything with the lung? VATS?

Breast: all mostly fair game?

GI / Abdomen: The bread and butter. Basically, all fair game minus the complex hepatobiliary stuff.

EGDs. Possible to get cert in ERCP?

Colorectal: colectomy, hemorrhoids, pilonidal, fistula, c-scope

GU: vasectomy? TURP??? C-sections?

Vascular: Ports. Amputations? AV fistula? Heard of general guys do some bypass and carotids, not sure how realistic this is and how comfortable one would be without extra vascular training.

Skin/Soft tissue: lumps, bumps, melanoma, squamous and basal. Carpal tunnel release? Ganglion cyst?

Misc. c-lines and c-tubes needed. Wound care?

H&N: thyroids, parathyroids, trachs, node biopsies. Problem with thyroids and parathyroids may be volume depending on your population base.
Thoracic: think more chest tubes at most. Again, volume is going to be a problem with bigger cases. If the general surgeon is doing thoracic, it's probably a small hospital where volume is very low and staff is unlikely to be "good" at managing these patients post op. I would stay far away from intra-thoracic esophageal work without additional training, the complications when those cases go bad are catastrophic. You will probably gain an appreciation for that as you get further along in your training.
Breast: fair game but is increasingly tough to keep up with current guidelines if you aren't doing a lot of it. It's not the technical aspect of surgery that's the issue, it's the management. If you're the only game in town you'll probably have the volume to stay up to date.
GI/Abd: hiatals and nissens maybe, if you are comfortable and had enough volume in residency. Obviously can do colons, appys, choles, etc.
EGDs and colonoscopies: lots of these if no/limited GI docs. this often makes up the majority of a rural surgeon's practice.
ERCP: need additional training.
GU/Gyn: some jobs will train you for c sections, but this is usually in hospitals without OB/Gyns so FPs are doing deliveries. vasectomy is reasonable. hydroceles and circs too. TURP no. Tubals, yes. Can do hysts with enough exposure but does your training allow you to know when it's indicated and when other things should be tried first?
Vascular: ports, amps, HD caths, PD caths, maybe fistulas if good IR support. I don't know many general surgeons under 50 without vascular fellowship training who do carotids or bypasses, so doubtful unless you have partners who do it and would mentor you along.
SST: carpal tunnel release sure, but ortho and plastics did all these where I trained. Never saw one in residency.

 

[anonperson]

PGY-1 more than halfway through intern year. We get into the OR quite a bit at my program even at the junior level. At this time in my very early career, I think I am going to purse community / somewhat rural general surgery practice. I really would like to work outside strictly the abdomen as a general surgeon. My question is how feasible, REALISTIC and safe is this with 5 years of general surgery training?

Head and Neck / Endocrine: Thyroids. Parathyroids? Anything else fair game in this region?

Thoracic: Not sure what’s fair game here for a general guy. Any esophageal work? Hiatal? Nissen? Anything with the lung? VATS?

Breast: all mostly fair game?

GI / Abdomen: The bread and butter. Basically, all fair game minus the complex hepatobiliary stuff.

EGDs. Possible to get cert in ERCP?

Colorectal: colectomy, hemorrhoids, pilonidal, fistula, c-scope

GU: vasectomy? TURP??? C-sections?

Vascular: Ports. Amputations? AV fistula? Heard of general guys do some bypass and carotids, not sure how realistic this is and how comfortable one would be without extra vascular training.

Skin/Soft tissue: lumps, bumps, melanoma, squamous and basal. Carpal tunnel release? Ganglion cyst?

Misc. c-lines and c-tubes needed. Wound care?

The reality is there is too much for a general surgeon to be good at everything. Like has been mentioned before, it's not just the technical aspect of operating but when to operate as well

Where I did residency (OBGYN) they were developing a rotation for people to get comfortable if they were going to be rural surgeons. This meant getting practice with c sections etc.

Doing c sections is fairly easy and this would probably be in a situation with a family doctor who does OB but maybe not c sections.

Hysterectomies aren't technically difficult either. Would you just do them open or are you doing to learn to do a laparoscopic hysterectomy or vaginal hysterectomy? Same surgery but there is enough differences due to approach that it can be tricky. And it is nice to offer patients a minimally invasive approach.

This is just some of the nuance with OBGYN which is a relatively small slice of the pie.

 

[DOVinciRobot]

Thanks for the replies.

I suppose what has me scratching my head is why i don't see this broad scope of practice as much and if there is something I'm missing in terms of my potential goals.

It seems that the general guys I've worked with so far want nothing outside the abdomen. If they do, they pursue fellowship to focus on just that area/region and then want nothing to do with general/ the abdomen.

You probably just don’t see those types of places in your training right now. We have a high volume community/rural site and the surgeons we work with do a lot of what you mention. The key is knowing when something really is too complex to be done by someone who isn’t doing that on a regular basis. For example, we see a good amount of rectal cancer out there and they feel comfortable doing LAR’s, but if it would require a coloanal or APR they get shipped to the specialist.

So lots of breast, abdominal, lines/tubes, scopes, colorectal, decent thyroid and parathyroid, and skin stuff. It’s honestly our best rotation and is an example of true general surgery that I think a lot of people who have been isolated at big academic centers have forgotten is critical to communities.

What they don’t do is the vascular/thoracic/OB/Uro stuff you mention. We do a LOT of vascular in our program, and I can’t really see me doing patients a service by doing their AVF when I’m done. I could technically do it, but when they inevitably need a more complex access or have a problem they’ll need to be sent to the specialist anyway.

 

[Surgeon D.O.]

Reading through these is helpful.

I suppose I am just trying to see to what extent I can hold on to that "head to toe" general surgery skill set.

The attendings I currently work with used to do VATS, Whipples, ERCP, TURPs with 2 of them still doing urgent/emergent ERCPs actually. They don't do Whipples anymore which I completely agree with lol. One will occasionally do a Vasc port, but several of them are aging and slowly peeling away their workload. My program is also a small community program which allows them to have a foot in more specialties at times.

 

[LucidSplash]

If you can graduate with adequate ERCP skills that would be a boon to most rural locations. Not all GI docs do ERCP and sometimes finding one who does for a smaller rural hospital can be tough so many times those patients get sent out if they need that.

For specific skills like that which are NOT common for a general surgeon to have, you should discuss with your attendings who do have those skills and make your interest clear. Find out how they picked up those skills and whether they think it will be possible for you to finish training with adequate skills and if not, where they did their additional training to become proficient and get credentialed.

And make sure you are tracking this stuff in your case log. That will ultimately determine what you can get privileges for when you finish training.

 

[cpants]

Reading through these is helpful.

I suppose I am just trying to see to what extent I can hold on to that "head to toe" general surgery skill set.

The attendings I currently work with used to do VATS, Whipples, ERCP, TURPs with 2 of them still doing urgent/emergent ERCPs actually. They don't do Whipples anymore which I completely agree with lol. One will occasionally do a Vasc port, but several of them are aging and slowly peeling away their workload. My program is also a small community program which allows them to have a foot in more specialties at times.

You should not do TURPs. I find it very surprising there are general surgeons doing them. It is not a very easy operation technically, especially if you do not already have robust endourology skills. The complications could be severe -- bleeding, bladder perforations, TUR syndrome. Not to mention it's easy to make someone totally incontinent if you don't know what you are doing. I would imagine there would be significant liability concerns for a general surgeon doing TURPs.

 

[Pir8DeacDoc]

I'm happy for you to do tonsillectomy if you're willing to take care of the bleeds after. Lol

I had a very rural satellite clinic where a general surgeon did tonsillectomy. He called me once to the OR for a hand with bleeding. Truthfully. When it's easy it's easy. But it can really suck. And lord the phone calls afterwards.

Anyway. Best wishes as you launch deeper into your career and training

 

[Banco]

The real question is, do you really want to be doing all of this, and will you be able to do it well without sacrificing quality. Of the things you have listed, I'd probably break it down as such:

Realistic:

• Breast: all mostly fair game
• GI / Abdomen: The bread and butter.
• Colorectal: colectomy, hemorrhoids, pilonidal, fistula, c-scope
• Vascular: Ports. Amputations.
• Skin/Soft tissue: lumps, bumps, melanoma, squamous and basal.
• Misc. c-lines and c-tubes needed. Wound care
• EGDs.

Possible if you're high volume:

• Head and Neck / Endocrine: Thyroids. Parathyroids
• Thoracic: esophageal work, Hiatal, Nissen
• Vascular: AV-fistula

Unrealistic:

• Anything with the lung, VATS.
• Complex hepatobiliary
• ERCP
• GU: vasectomy? TURP??? C-sections?
• Vascular: Bypass/Carotid
• Carpal tunnel release

 

[Dr.LeoSpaceman]

The real question is, do you really want to be doing all of this, and will you be able to do it well without sacrificing quality. Of the things you have listed, I'd probably break it down as such:

Seems very reasonable. I'd also throw in that even colorectal may not be a monolith anymore. For anything (cancer-related) below the peritoneal reflection, there is some benefit to not only being high volume, but also going to depend on your multi-D setup. Having good med oncs and rad oncs (plus access to good quality pelvic MRI) should be part of the deal.

 

[SurgDoc95]

Reading through these is helpful.

I suppose I am just trying to see to what extent I can hold on to that "head to toe" general surgery skill set.

The attendings I currently work with used to do VATS, Whipples, ERCP, TURPs with 2 of them still doing urgent/emergent ERCPs actually. They don't do Whipples anymore which I completely agree with lol. One will occasionally do a Vasc port, but several of them are aging and slowly peeling away their workload. My program is also a small community program which allows them to have a foot in more specialties at times.

In the context of trauma VATS isn't unreasonable for a general surgeon with enough experience. Doesn't take a thoracic surgeon to do an early washout imo

 

[Lem0nz]

From a practical perspective and because I think people will find it interesting:

We have no gyn-onc where I am for many, many hours in any direction. I have been doing TAH/BSO by myself for cancer only.

The hoops and hurdles to do so, get credentialed to do so, to get liability insurance to do so, for the gynecologists who DON'T and CAN'T do these operations because of their own professional societies to agree to me to do it, and the microscope I am under every single time I do it... it is absolutely nuts. And this place HIRED me asking me to do these operations specifically.

It was 1000% not worth the grief and I would not do this again if I knew what it required of my time and my patience. And now that I'm doing it and it is a fairly serious part of my practice there is a constant effort to hire a gyn-onc to replace that part of my practice which drives me insane.

So, be wary. FYI I am a surgical oncologist and have done ~70 robotic TAH/BSO now. Did ~30 in fellowship robot, ~20 open.

 

[ThoracicGuy]

From a practical perspective and because I think people will find it interesting:

We have no gyn-onc where I am for many, many hours in any direction. I have been doing TAH/BSO by myself for cancer only.

The hoops and hurdles to do so, get credentialed to do so, to get liability insurance to do so, for the gynecologists who DON'T and CAN'T do these operations because of their own professional societies to agree to me to do it, and the microscope I am under every single time I do it... it is absolutely nuts. And this place HIRED me asking me to do these operations specifically.

It was 1000% not worth the grief and I would not do this again if I knew what it required of my time and my patience. And now that I'm doing it and it is a fairly serious part of my practice there is a constant effort to hire a gyn-onc to replace that part of my practice which drives me insane.

So, be wary. FYI I am a surgical oncologist and have done ~70 robotic TAH/BSO now. Did ~30 in fellowship robot, ~20 open.

Being where you are, I expect you do a bunch of stuff that a surg onc in Dallas or NYC or LA would never ever do. I'm not sure I could ever take a job like that.

 

[Lem0nz]

Being where you are, I expect you do a bunch of stuff that a surg onc in Dallas or NYC or LA would never ever do. I'm not sure I could ever take a job like that.

I definitely do 'full spectrum' surg onc which is exceptionally rare now. I imagine there's probably only ~50 people in the country that practice with this sort of scope. Trade offs are my volumes are now much lower in the big things. I would not meet criteria for what is considered adequate for high volume in a lot of what I do but there's no one else in the entire state so no one cares. I don't mind either, I do enough weird benign things now that is all in the same anatomical field that the whipples and big right/left livers, etc. all feel like easy operations compared to... the other weirdness that comes through the door.

 

[ThoracicGuy]

I definitely do 'full spectrum' surg onc which is exceptionally rare now. I imagine there's probably only ~50 people in the country that practice with this sort of scope. Trade offs are my volumes are now much lower in the big things. I would not meet criteria for what is considered adequate for high volume in a lot of what I do but there's no one else in the entire state so no one cares. I don't mind either, I do enough weird benign things now that is all in the same anatomical field that the whipples and big right/left livers, etc. all feel like easy operations compared to... the other weirdness that comes through the door.

Definitely gives you good job security there...